Joint surgical treatment

ABSTRACT

A joint surgical treatment under an arthroscope, includes: excising a treatment object of a synovial membrane, by transmitting an ultrasonic vibration to a treating portion of an ultrasonic device in a state where the treating portion is in contact with the treatment object of the synovial membrane; facing the treating portion to a treatment object of a cartilage, the treating portion being used in excising the treatment object of the synovial membrane; and removing the treatment object of the cartilage, by contacting the treating portion with the treatment object of the cartilage, and by transmitting the ultrasonic vibration to the treating portion in a state where the treating portion is in contact with the treatment object of the cartilage.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention relates to a surgical treatment of a joint to beperformed under an arthroscope.

2. Description of the Related Art

It is known that, when performing an arthroscopic surgical treatment fora patient's joint such as a knee joint, an elbow joint or a shoulderjoint, a surgeon proceeds with the treatment while inserting andremoving treatment devices through a portal many times in accordancewith a tissue of a treatment region with the progress of the treatment,and the above treatment devices are, for example, a shaver to shave asoft tissue, an abrader burr to abrade a bone, or an RF device to excisethe soft tissue while stopping bleeding.

BRIEF SUMMARY OF THE INVENTION

According to one aspect of the present invention, a joint surgicaltreatment which is to be performed under an arthroscope, the surgicaltreatment includes: inserting the arthroscope and a treating portion ofan ultrasonic device into a joint; excising a treatment object region ofa synovial membrane, by transmitting an ultrasonic vibration to thetreating portion in a state where the treating portion is in contactwith the treatment object region of the synovial membrane whileobserving the treating portion of the ultrasonic device and thetreatment object region of the synovial membrane with the arthroscope;approaching and facing the treating portion of the ultrasonic device toa treatment object region of a cartilage, the treating portion of theultrasonic device being used in excising the treatment object region ofthe synovial membrane; and removing the treatment object region of thecartilage, by bringing the treating portion of the ultrasonic deviceinto contact with the treatment object region of the cartilage, and bytransmitting the ultrasonic vibration to the treating portion in a statewhere the treating portion is in contact with the treatment objectregion of the cartilage while observing the treating portion and thetreatment object region of the cartilage with the arthroscope.

Advantages of the invention will be set forth in the description whichfollows, and in part will be obvious from the description, or may belearned by practice of the invention. The advantages of the inventionmay be realized and obtained by means of the instrumentalities andcombinations particularly pointed out hereinafter.

BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWING

The accompanying drawings, which are incorporated in and constitute apart of the specification, illustrate embodiments of the invention, andtogether with the general description given above and the detaileddescription of the embodiments given below, serve to explain theprinciples of the invention.

FIG. 1 is a schematic view showing a treatment system for use in asurgical treatment of a knee joint;

FIG. 2 is a schematic view showing one example of an ultrasonictreatment device (an ultrasonic device) of the treatment system for usein the surgical treatment of the knee joint;

FIG. 3 is a schematic view showing a state where an arthroscope and atreating portion of the ultrasonic treatment device are inserted fromseparate portals, respectively, to an articular capsule of the kneejoint of a right knee seen from the anterior side;

FIG. 4 is a schematic side view showing a state where the knee joint ofthe right knee encapsulated in the articular capsule is seen from themedial side;

FIG. 5 is a schematic view showing a state where a medial meniscus, alateral meniscus, an anterior cruciate ligament and a posterior cruciateligament of the knee joint of the right knee are seen from the superiorside;

FIG. 6 is a schematic coronary cross-sectional view schematicallyshowing a state where there is inflammation of a synovial membrane inthe articular capsule of the knee joint;

FIG. 7 is a schematic view showing a state where an ultrasonic vibrationis transmitted to the treating portion of the ultrasonic treatmentdevice to excise the synovial membrane in the articular capsule of theknee joint under the arthroscope;

FIG. 8 is a schematic view showing a state where the ultrasonicvibration is transmitted to the treating portion of the ultrasonictreatment device to excise a damaged region of the meniscus of the kneejoint under the arthroscope;

FIG. 9A is a schematic view showing a state where a condition of acartilage of a joint excised with the treating portion of the ultrasonictreatment device to which the ultrasonic vibration is transmitted isenlarged and observed;

FIG. 9B is a schematic view showing a state where a condition of thecartilage of the joint abraded with an abrader burr is enlarged andobserved;

FIG. 9C is a schematic view showing a state where a condition of thecartilage of the joint excised with an RF device is enlarged andobserved;

FIG. 10A is a schematic view showing a state where the ultrasonicvibration is transmitted to the treating portion of the ultrasonictreatment device to remove a treatment object region of the cartilage ofthe knee joint under the arthroscope;

FIG. 10B is a schematic view showing a condition where of a treatedsurface formed by the treating portion of the ultrasonic treatmentdevice when the ultrasonic vibration is transmitted to the treatingportion of the ultrasonic treatment device to remove the treatmentobject region of the cartilage of the knee joint under the arthroscope;

FIG. 11A is a schematic view showing a state where the ultrasonicvibration is transmitted to the treating portion of the ultrasonictreatment device to dissect the anterior cruciate ligament of a femurside of the knee joint under the arthroscope;

FIG. 11B is a schematic view showing a state where the ultrasonicvibration is transmitted to the treating portion of the ultrasonictreatment device to dissect the anterior cruciate ligament of the femurside of the knee joint under the arthroscope, thereby exposing afootprint region (a region to which the anterior cruciate ligament isattached);

FIG. 11C is a schematic view showing a state where a concave hole (aconcave region) is formed from the footprint region toward a lateralsurface of a lateral condyle of the femur with the treating portion ofthe ultrasonic treatment device from which the ultrasonic vibration istransmitted to the footprint region of the anterior cruciate ligament ofthe femur side of the knee joint under the arthroscope;

FIG. 12A is a schematic view showing a state where the ultrasonicvibration is transmitted to the treating portion of the ultrasonictreatment device to dissect the anterior cruciate ligament of a tibiaside of the knee joint under the arthroscope;

FIG. 12B is a schematic view showing a state where the ultrasonicvibration is transmitted to the treating portion of the ultrasonictreatment device to dissect the anterior cruciate ligament of the tibiaside of the knee joint under the arthroscope, thereby exposing thefootprint region (the region to which the anterior cruciate ligament isattached);

FIG. 12C is a schematic view showing a state where a concave hole (aconcave region) is formed from the footprint region toward a medial sideof a rough surface of the tibia with the treating portion of theultrasonic treatment device from which the ultrasonic vibration istransmitted to the footprint region of the anterior cruciate ligament ofthe tibia side of the knee joint under the arthroscope;

FIG. 13A is a schematic view showing a state where one end of aninstrument that guides a drill to form a tunnel in a tibia is disposedin the footprint region of the anterior cruciate ligament of the tibiaside of the knee joint or the concave hole formed in the footprintregion, and the drill can be guided from the other end present on anouter rough surface side of the tibia toward the one end;

FIG. 13B is a schematic view showing a state where one end of aninstrument that guides a drill to form a tunnel in a femur is disposedin the footprint region of the anterior cruciate ligament of the femurside of the knee joint or the concave hole formed in the footprintregion, and the drill can be guided from the other end thereof on anouter side of the femur toward the one end;

FIG. 14 is a schematic view showing a state where a graft is interposedbetween a tunnel on the femur side and a tunnel on the tibia side to fixend portions of the graft to outer sides of the femur and the tibia,respectively;

FIG. 15A is a schematic view showing the treatment system for use in asurgical treatment of a shoulder joint;

FIG. 15B is a schematic view showing a part of the treatment system ofFIG. 15A in detail;

FIG. 16A is a side view showing an ultrasonic probe of the treatmentdevice of the treatment system shown in FIG. 15B;

FIG. 16B is a top view of the ultrasonic probe shown in FIG. 16A;

FIG. 17 is a schematic view showing a patient fixed to a beach chair;

FIG. 18 is a schematic view of positions of a skeleton around a rightshoulder joint and a scapula upper arm joint which are seen from theanterior side;

FIG. 19 is a perspective view of an anatomical structure of the scapulaupper arm joint which is seen from the anterior side;

FIG. 20 is a schematic view showing each portal to access the scapulaupper arm joint from a superior side direction of the patient;

FIG. 21 is a perspective view showing a step of debriding a torn labrumfrom a glenoid by use of the ultrasonic probe in Bankart repair;

FIG. 22 is a perspective view showing a step of peeling the labrum fromthe glenoid by use of the ultrasonic probe in the Bankart repair;

FIG. 23A is a schematic view showing a state where the labrum is suturedat a correct position by use of anchors and sutures in a labrum ligamentcomplex;

FIG. 23B is a cross-sectional view schematically showing the labrumcompletely peeled from the glenoid;

FIG. 23C is a cross-sectional view schematically showing a state wherean anchor of the anchors and sutures is fixed to a hard tissue of theglenoid;

FIG. 23D is a cross-sectional view schematically showing a state wherethe suturing of the labrum is completed by using the anchors andsutures;

FIG. 24 is a perspective view showing a treatment of cleaning a position(the footprint region) of a root of a subscapular muscle tendon with theultrasonic probe in repair of the subscapular muscle tendon in shoulderrotator cuff repair;

FIG. 25A is a perspective view showing a state where the subscapularmuscle tendon is fixed to a humerus by the anchors and sutures in therepair of the subscapular muscle tendon;

FIG. 25B is a perspective view schematically showing a state where thesubscapular muscle tendon is fixed to the humerus by the anchors andsutures in the repair;

FIG. 26 is an anterior side view showing the anatomical structure arounda scapula upper arm joint;

FIG. 27 is a perspective view showing an affected area in which the cuffis torn;

FIG. 28 is a side view showing a treatment of debriding the torn cuffshown in FIG. 27 by use of the ultrasonic probe;

FIG. 29 is a perspective view showing a treatment of removing asubacromial bone spur in the shoulder rotator cuff repair;

FIG. 30 is a schematic view showing a state where the anchor is fixed tothe humerus and then the cuff is being fixed by using the sutures in theshoulder rotator cuff repair;

FIG. 31 is a schematic view showing a state where the cuff is fixed withthe sutures in the shoulder rotator cuff repair shown in FIG. 30;

FIG. 32 is a schematic view showing a treatment system for use in asurgical treatment of an elbow joint;

FIG. 33 is a schematic view of a right elbow joint seen from an anteriorside of a human body;

FIG. 34 is a schematic view of the right elbow joint seen from aposterior side (a rear side) of the human body;

FIG. 35 is a schematic view schematically showing the right elbow jointtogether with the articular capsule;

FIG. 36 is a schematic view showing running of nerves in the right elbowjoint and the vicinity of the right elbow joint;

FIG. 37 is a schematic view showing a state where the ultrasonicvibration is transmitted to the treating portion of the ultrasonictreatment device to excise the synovial membrane in the articularcapsule of the elbow joint under the arthroscope;

FIG. 38A is a schematic view showing a state where the treating portionof the ultrasonic treatment device is brought into contact with the bonespur of the elbow joint under the arthroscope;

FIG. 38B is a schematic view showing a state where the ultrasonicvibration is transmitted to the treating portion of the ultrasonictreatment device to remove the bone spur of the elbow joint under thearthroscope;

FIG. 39 is a schematic view showing a state where the ultrasonicvibration is transmitted to the treating portion of the ultrasonictreatment device to remove the treatment object region of the cartilageof the elbow joint under the arthroscope;

FIG. 40A is a schematic view showing, in a cross section, a removedsurface cut off by using the ultrasonic vibration to the treatingportion of the ultrasonic treatment device and a non-removed surfaceadjacent to the removed surface, in the cartilage of the elbow joint;and

FIG. 40B is a schematic view showing, in a cross section, a removedsurface cut off with the abrader burr and a non-removed surface adjacentto the removed surface, in the cartilage of the elbow joint.

DETAILED DESCRIPTION OF THE INVENTION

Embodiments of this invention will be described with reference to thedrawings.

Knee Joint

When a knee joint 100 is treated, for example, a treatment system 10shown in FIG. 1 is used. The treatment system 10 has an arthroscopedevice 12, a treatment device 14, and a perfusion device 16.

The arthroscope device 12 includes an arthroscope 22 to observe an innerpart of the knee joint 100, i.e., the inside of a joint cavity 136 of apatient, an arthroscope controller 24 that performs image processing onthe basis of a subject image imaged by the arthroscope 22, and a monitor26 that displays the image generated by the image processing in thearthroscope controller 24. The arthroscope 22 is inserted into the jointcavity 136 of the knee joint 100 through a first cannula 18 a that formsa lateral portal 102 via which the inner part of the knee joint 100 ofthe patient communicates with an outer side of skin. It is to be notedthat a position of the portal 102 is not uniform but is suitablydetermined in accordance with a patient's condition.

The treatment device 14 has an ultrasonic treatment device 32, atreatment device controller 34, and a switch 36. Here, the treatmentdevice controller 34 supplies energy to the ultrasonic treatment device32 in accordance with an operation of the switch 36 to transmit anultrasonic vibration to a treating portion 68 of an after-mentionedprobe 66 of the ultrasonic treatment device 32. The treatment device 32is inserted into the joint cavity 136 of the knee joint 100 through asecond cannula 18 b that forms a medial portal 104 via which the innerpart of the joint 100 of the patient communicates with the outer side ofthe skin. It is to be noted that a position of the portal 104 is notuniform but is suitably determined in accordance with the patient'scondition. The switch 36 maintains, for example, a driven state of anultrasonic transducer in a state where the switch is pressed to beoperated, and when the pressed state is released, the driven state ofthe ultrasonic transducer is released.

Here, it is described that the one switch 36 is disposed, but theswitches may be disposed. An amplitude of the ultrasonic transducer cansuitably be set by the treatment device controller 34. In consequence,by the operation of the switch 36, a frequency of the ultrasonicvibration to be output from the after-mentioned ultrasonic transducer isthe same, but the amplitude may be different. Therefore, the switch 36can suitably switch the amplitude of the ultrasonic transducer to statessuch as two large and small states. For example, when the amplitude canbe switched to the two large and small states, the ultrasonic vibrationof the small amplitude is for use in treating comparatively soft tissuessuch as a synovial membrane 134, cartilages 112 a, 114 a and 118 a, andmeniscuses 142 and 144 shown in FIG. 3 to FIG. 5. The ultrasonicvibration of the large amplitude is for use in treating comparativelyhard tissues such as bones (a femur 112, a tibia 114 and a patella 118)shown in FIG. 3 and FIG. 4. Additionally, the amplitude of theultrasonic vibration in a case where a treatment object region of thesynovial membrane 134 is excised is preferably smaller than an amplitudein a case where a treatment object region of the meniscus 142 or 144 orthe after-mentioned cartilage 112 a, 114 a or 118 a is removed. Inaddition, the amplitude of the ultrasonic vibration in a case where abone tissue (the hard tissue) such as a bone spur is removed ispreferably larger than the amplitude of the ultrasonic vibration in acase where the treatment object region (the soft tissue) of thecartilage 112 a, 114 a or 118 a is removed.

It is to be noted that, for example, the two switches 36 may be disposedin parallel, or a hand switch and a foot switch may selectively be used.Additionally, when the one switch 36 is switched to be used, theultrasonic vibration of the small amplitude may be output by oneoperation, and the ultrasonic vibration of the large amplitude may beoutput by two quick pressing operations as in a double click operationof a mouse for a computer.

The perfusion device 16 includes a bag-shaped liquid source 42 thatcontains a perfusion liquid such as physiological saline, a perfusionpump unit 44, a liquid supply tube 46 whose one end is connected to theliquid source 42, a liquid discharge tube 48, and a suction bottle 50connected to one end of the liquid discharge tube 48. The suction bottle50 is connected to a suction source attached to a wall of an operatingroom. In the perfusion pump unit 44, the perfusion liquid can besupplied from the liquid source 42 by a liquid supply pump 44 a.Additionally, in the perfusion pump unit 44, suction/suction stop of theperfusion liquid in the joint cavity 136 of the knee joint 100 to thesuction bottle 50 can be switched by opening/closing a pinching valve 44b as a liquid discharge valve.

The other end of the liquid supply tube 46 that is a liquid supply tubepath is connected to the first cannula 18 a. In consequence, theperfusion liquid can be supplied into the joint cavity 136 of the kneejoint 100 via the first cannula 18 a. The other end of the liquiddischarge tube 48 that is a liquid discharge tube path is connected tothe first cannula 18 a. In consequence, the perfusion liquid can bedischarged from the joint cavity 136 of the knee joint 100 via the firstcannula 18 a. It is to be noted that, needless to say, the other end ofthe liquid discharge tube 48 may be connected to the second cannula 18b, so that the perfusion liquid can be discharged from the knee joint100.

It is to be noted that, here, the perfusion liquid can be supplied anddischarged through the first cannula 18 a, but a function that iscapable of supplying and/or discharging the perfusion liquid may beimparted to, for example, the arthroscope 22. Similarly, the functionthat is capable of supplying and/or discharging the perfusion liquid maybe imparted to the ultrasonic treatment device 32. In addition, afunction that is capable of supplying and discharging the perfusionliquid through the second cannula 18 b may be imparted. Furthermore, theperfusion liquid may be supplied and discharged through separateportals.

As shown in FIG. 2, the ultrasonic treatment device 32 includes ahousing 62, a sheath 64 projected from the housing 62, and the probe 66inserted into the sheath 64. In particular, outer peripheral surfaces ofthe housing 62 and the sheath 64 have insulating properties. The probe66 is made of a metal material such as a titan alloy material capable oftransmitting the ultrasonic vibration. To a proximal end of the probe66, there is fixed an unshown ultrasonic transducer unit disposed in thehousing 62. In the ultrasonic treatment device 32, the treating portion68 of the probe 66 inserted into the sheath 64 is disposed together withthe sheath 64 in the joint cavity 136 through the second cannula 18 b.Further, when the switch 36 is pressed, energy is supplied from thetreatment device controller 34 to the ultrasonic transducer unit fixedto the proximal end of the probe 66, and the ultrasonic transducerultrasonically vibrates. This vibration is transmitted from the proximalend of the probe 66 toward a distal end side, and hence with the aid ofthe treating portion 68 of a distal end of the probe 66, the hard tissue(the bone tissue or the like) can be resected and the soft tissue (thecartilage, a membrane tissue or the like) can be excised.

It is to be noted that a shape of the treating portion 68 can suitablybe selected in accordance with a treatment region. Here, there isdescribed an example where a hook type of treating portion shown in FIG.2 is used, but various shapes such as a rake type, a blade type and acurette type can selectively be used in consideration of anaccessibility to the treatment region, an adaptability to the treatmenton the basis of a position, a shape, a size or the like of a bladeportion of the treating portion 68, or the like.

A structure of the knee joint 100 will briefly be described.Hereinafter, the knee joint 100 of a right knee will be described as anexample.

As shown in FIG. 3, the knee joint 100 is mainly constituted of a femur112, a tibia 114, a fibula 116, and a patella 118. As shown in FIG. 4,the knee joint 100 is encapsulated in a joint capsule 130. The jointcapsule 130 includes a fibrous tunica 132 on a lateral side and thesynovial membrane 134 on a medial side. The synovial membrane 134 formspleats and secretes a synovial fluid, and hence the knee joint 100smoothly moves. The inside of the joint capsule 130 is called the jointcavity 136. The joint cavity 136 is filled with the synovial fluid to besecreted from the synovial membrane 134. The joint cavity 136 of theknee joint 100 is incompletely divided into four cavities (asuprapatellar bursa, a patellofemoral joint cavity, a lateralfemorotibial joint cavity and a medial femorotibial joint cavity), andthe synovial membrane pleat is present as a partition wall between thesecavities.

Additionally, in the knee joint 100, each of the cartilages (jointcartilages) 112 a, 114 a and 118 a is present between the bones (thefemur 112, the tibia 114 and the patella 118). By the cartilages 112 a,114 a and 118 a, impact can be absorbed in the knee joint 100, and theknee joint 100 can smoothly move.

As shown in FIG. 3, surfaces of the femur 112 which are joined to thetibia 114 are referred to as a medial condyle 122 and a lateral condyle124, respectively. In a superior surface of the tibia 114, there are twosurfaces to be joined to the medial condyle 122 and the lateral condyle124 of the femur 112. Between the medial condyle 122 and the lateralcondyle 124 of the femur 112 and the upper surface of the tibia 114, themeniscuses 142 and 144 and ligaments 152 and 154 adhere.

As shown in FIG. 5, the meniscuses 142 and 144 form a pair on lateraland medial sides. A superior surface of the medial meniscus 142 extendsalong the spherical cartilage 112 a disposed in the medial condyle 122of the femur 112, and an inferior surface of the medial meniscus extendsalong the flat cartilage 114 a disposed on the superior surface of thetibia 114. Similarly, a superior surface of the lateral meniscus 144extends along the spherical cartilage 112 a disposed in the lateralcondyle 124 of the femur 112, and an inferior surface of the lateralmeniscus extends along the flat cartilage 114 a disposed on the superiorsurface of the tibia 114. Consequently, the meniscuses 142 and 144 areformed so that lateral edge portions of the meniscuses are thick andmedial edge portions of the meniscuses are thin. It is to be noted thatthe lateral edge portions of the medial meniscus 142 and the lateralmeniscus 144 are linked to the joint capsule 130.

In the knee joint 100, an anterior cruciate ligament 152 and a posteriorcruciate ligament 154 are present. When the knee joint 100 is seen froman anterior side, the anterior cruciate ligament 152 is present in theanterior side and the posterior cruciate ligament 154 is present in aposterior side. One end of the anterior cruciate ligament 152 is passedthrough a space between the medial condyle 122 and the lateral condyle124 of the femur 112 and fixed to the posterior side of the femur, andthe other end of the anterior cruciate ligament is fixed to the anteriorside of the superior surface of the tibia 114. The anterior cruciateligament 152 has its start region in a medial surface posterior regionof the lateral condyle 124 of the femur 112, and adheres to an anteriorintercondylar fossa area (an end region) of the tibia 114. One end ofthe posterior cruciate ligament 154 is fixed to a slightly anteriorregion of the femur 112, and the other end of the posterior cruciateligament is fixed to the posterior side of the superior surface of thetibia 114. The posterior cruciate ligament 154 has its start region in alateral surface anterior region of the medial condyle 122 of the femur112, and adheres to a posterior intercondylar fossa area (an end region)of the tibia 114.

Next, there will be described a method in which a surgeon (an operator)uses the treatment system 10 mentioned above to excise a damaged regionof the meniscus 142 or 144 under the arthroscope 22 to the patient whohas the damaged region in at least one of the meniscuses 142 and 144present between the femur 112 and the tibia 114 of the knee joint 100.

As to the damage of the meniscus 142 or 144 of the knee joint 100, ingeneral, there are a case where the meniscus is damaged due to anexternal injury or the like and a case where the meniscus is damaged dueto repeatedly loaded stress. As to the meniscus 142 or 144, the damagesare mainly and often caused to an anterior horn of the medial meniscus142 or posterior regions (posterior horns or posterior nodes) of themedial meniscus 142 and the lateral meniscus 144. In addition, when themeniscus 142 or 144 is damaged, as shown in FIG. 6, such inflammation asshown by a reference sign 134 a might be caused to the meniscus togetherwith the synovial membrane 134.

A condition of the knee joint 100 is confirmed by use of an X-ray, MRIor the like. When the damage is confirmed in the meniscus 142 or 144, adamaged condition of the meniscus 142 or 144 is confirmed in advance.

There are prepared an instrument to form the portals 102 and 104 in theknee joint 100, and an instrument for use in a surgical treatment ofexcising an inflamed region of the synovial membrane 134 and damagedregions of the meniscuses 142 and 144. It is to be noted that thetreating portion 68 of the ultrasonic treatment device 32 is formed intoa suitable shape such as the hook type.

The surgeon forms the first portal 102 on anterior and lateral side ofthe knee joint to the patient who bends the knee joint 100 of the rightknee. When necessary, the first cannula 18 a is disposed in the portal102. A distal end of the arthroscope 22 is disposed in the joint cavity136 of the knee joint 100 through the first cannula 18 a. Here, thefirst cannula 18 a is not necessarily required, when the perfusiondevice 16 is connectable to the arthroscope 22.

The joint cavity 136 of the knee joint 100 is filled with saline by useof the perfusion device 16. In this state, the medial side of the jointcavity 136 of the knee joint 100 is suitably observed by using thearthroscope 22. Further, the damaged region of the meniscus 142 or 144is disposed in a view field of the arthroscope 22 to confirm the damage.In addition, an inflamed condition of the synovial membrane 134 on themedial side of the joint capsule 130 of the knee joint 100 is confirmed.

The surgeon forms the second portal 104 on the anterior and medial sideto the patient who bends the knee joint 100. When necessary, the secondcannula 18 b is disposed in the portal 104. The treating portion 68 ofthe ultrasonic treatment device 32 is disposed in the joint cavity 136of the knee joint 100 through the second cannula 18 b. When the inflamedregion is present in the synovial membrane 134 of the joint capsule 130confirmed with the arthroscope 22, as shown in FIG. 7, the surgeonapproaches the inflamed region with the treating portion 68 of theultrasonic treatment device 32 to bring the treating portion intocontact with the inflamed region while observing the inflamed regionwith the arthroscope 22. Further, the surgeon operates the switch 36 ofthe treatment device 14 to generate the ultrasonic vibration of thesuitable amplitude in the ultrasonic transducer, thereby only moving thetreating portion 68 in an axial direction of the probe 66, whereby theinflamed region 134 a of the synovial membrane 134 and/or an inflamedsynovial membrane is excised with the treating portion 68 to which thevibration is transmitted. The excised inflamed region of the synovialmembrane 134 is flown with momentum in excising the region. At thistime, the surgeon suitably moves the ultrasonic treatment device 32 andalso suitably moves the arthroscope 22 to excise the inflamed region 134a of the synovial membrane 134 and/or the inflamed synovial membrane andfurther a peripheral region with the treating portion 68 of theultrasonic treatment device 32 while always disposing the treatingportion 68 in the view field of the arthroscope 22. In the synovialmembrane 134, the excised inflamed region 134 a and the peripheralregion are discharged to the suction bottle 50 through the first cannula18 a and the liquid discharge tube 48.

A head (a treating portion) of an unshown shaver that has heretoforebeen used in removing the inflamed region of the synovial membrane 134or the like has a structure to intertwine the inflamed region byperiaxial rotation. Thus, the shaver performs the treatment whileintertwining (winding) the inflamed region, and hence there is a highpossibility that a peripheral tissue in the knee joint 100 is woundduring the treatment. In addition, power is securely transmitted from amotor of the shaver to the head, and hence it is difficult to form aportion between the motor and the head of the shaver into a suitableshape, and additionally, a head portion is formed to be larger than thetreating portion 68 of the ultrasonic treatment device 32. Inconsequence, it is very difficult for the head portion of the shaver toespecially access the posterior side of the knee joint 100. Therefore,even by use of the shaver that has heretofore been used, it might bedifficult to remove the synovial membrane 134. When the treatment isperformed by using the ultrasonic treatment device 32, it is notnecessary to rotate the treating portion 68. Therefore, damages due tothe winding of the peripheral tissue in the knee joint 100 can bedecreased. In addition, when the treatment is performed by using theultrasonic treatment device 32, the treating portion 68 can be formedinto the suitable shape, the treating portion 68 can be formed to besmaller, and the probe 66 can be formed to be thinner, so that a movingrange of the treating portion 68 to the second cannula 18 b can beincreased. Therefore, in a case where the ultrasonic treatment device 32is used, for example, the posterior side of the knee joint 100 can moreeasily be accessed as compared with a case where the shaver is used.Consequently, in the case the ultrasonic treatment device 32 is used,the inflamed region of the synovial membrane 134 can more easily beexcised than in the case where the shaver is used.

In addition, as described above, the shaver has the structure tointertwine the inflamed regions of the synovial membrane 134 by theperiaxial rotation. Consequently, the shaver operates to tear off thesynovial membrane 134, and the excised region of the synovial membrane134 easily bleeds. On the other hand, the treating portion 68 of theultrasonic treatment device 32 does not periaxially rotate, and theinflamed region can be excised only by moving the treating portion inthe axial direction of the probe 66. Further, in the case where theultrasonic treatment device 32 is used, the excised region is flownunlike the case where the shaver is used, and hence the view field ofthe arthroscope 22, especially the view field of the treatment region iseasily acquired.

As described above, the surgeon removes the inflamed region of thesynovial membrane 134 by use of the ultrasonic treatment device 32, andthen while moving the arthroscope 22 to confirm the inside of the jointcavity 136 of the knee joint 100, the surgeon moves the ultrasonictreatment device 32 to dispose the damaged region of the meniscus 142 or144 in the view field of the arthroscope 22 as shown in FIG. 8.Furthermore, the treating portion 68 of the ultrasonic treatment device32 is disposed to face the damaged region of the meniscus 142 or 144.That is, here, the treating portion 68 of the ultrasonic treatmentdevice 32 that is the same as the portion used to excise the synovial.membrane 134 is disposed as it is to face the damaged region of themeniscus 142 or 144. Therefore, the treating portion 68 approachestreatment regions such as the anterior horn of the medial meniscus 142and the posterior horns and posterior nodes of the medial meniscus 142and the lateral meniscus 144 to face them. The treating portion 68 ofthe ultrasonic treatment device 32 is brought into contact with thetreatment region of the meniscus 142 or 144, and the switch 36 isoperated to generate the ultrasonic vibration of the suitable amplitudein the ultrasonic transducer. In consequence, the treating portion 68 towhich the ultrasonic vibration is transmitted is only moved in the axialdirection of the probe 66, to remove the damaged meniscus 142 or 144 inthe treatment region. That is, a region of the meniscus 142 or 144 inwhich tear or damage denaturation occurs is excised with the treatingportion 68 to which the ultrasonic vibration is transmitted, to performdissection. As shown in FIG. 10B, the surgeon can easily form a surfacetreated by the treating portion 68 of the ultrasonic treatment device 32to which the ultrasonic vibration is transmitted, as a smooth surfacewithout forming any corner portions in the treatment region of themeniscus 142 or 144 by suitably moving the treating portion 68 inaccordance with the movement of the probe 66 in the axial direction.When the treatment object region of the meniscus 142 or 144 is removed,a dented region having a substantially circular vertical cross sectionis formed, and there are smoothly continued a removed surface 146 fromwhich the treatment object region of the meniscus 142 or 144 is removedand a non-removed surface 148 (see FIG. 10B) adjacent to the removedsurface 146. In consequence, the region treated with the treatingportion 68 of the ultrasonic treatment device 32 by the surgeon is hardto be stuck on another region.

It is to be noted that, by the operation of the switch 36, the amplitudeof the ultrasonic transducer in a case where the synovial membrane 134is removed may be adjusted to be different from the amplitude of theultrasonic transducer in a case where the damaged region of the meniscus142 or 144 is excised.

It might be difficult for the unshown shaver head that has heretoforebeen used in shaving the bone to access the damaged region of themeniscus 142 or 144. The ultrasonic treatment device 32 can be formedinto a suitable shape between the proximal end of the probe 66 and thetreating portion 68 of the distal end, the treating portion 68 can beformed to be small, and hence the ultrasonic treatment device can moreeasily have access toward the posterior side of the knee joint 100 thanthe shaver. Consequently, in the case where the treatment is performedby using the ultrasonic treatment device 32, the damaged region of themeniscus 142 or 144 can more easily be excised than in the case wherethe shaver is used. Additionally, as shown in FIG. 9A, the surfacetreated by the ultrasonic treatment device 32 can smoothly be formed by,for example, a blade surface of the hook-shaped treating portion 68. Onthe other hand, the shaver shaves the surface by the rotation of thehead, and hence it is more difficult to smoothen the cut-off surfacethan in the case where the ultrasonic treatment device 32 is used.

It is to be noted that when an abrader burr is used in the treatment ofa soft tissue such as the meniscus 142 or 144, the treated surface (anabraded surface) is disadvantageously made fluffy as shown in FIG. 9B.Consequently, in the case where the abrader burr is used, it is moredifficult to smoothen the surface and it is easier to generate concaveand convex areas in the excised region than in the case where theultrasonic treatment device 32 is used. As shown in FIG. 9A and FIG. 9B,in the case where the treating portion 68 of the ultrasonic treatmentdevice 32 is used, the treated surface is more easily formed preciselyand smoothly than in the case where the abrader burr is used. Therefore,in the case where the ultrasonic treatment device 32 is used, theconcave and convex areas of the excised region can be decreased ascompared with the case where the abrader burr is used.

Thus, the ultrasonic treatment device 32 is used, and hence the devicecan smoothly be moved between the treatment region of the meniscus 142or 144 and the femur 112 and between the treatment region of themeniscus 142 or 144 and the tibia 114. Therefore, the treatment in whichthe ultrasonic treatment device 32 is used contributes to a smooth jointmovement in which sticking of the femur 112 to the meniscus 142 or 144that remains to be excised and sticking of the tibia 114 to the meniscus142 or 144 that remains to be excised are eliminated.

As described above, the surgeon performs the treatment of the damagedregion of the meniscus 142 or 144 to the patient. Afterward, the surgeonpulls out the treating portion 68 of the ultrasonic treatment device 32from the second cannula 18 b and pulls out the distal end of thearthroscope 22 from the first cannula 18 a. Furthermore, the first andsecond cannulas 18 a and 18 b are removed from the knee joint 100.Further, the portals 102 and 104 are sutured.

As described above, the technique of excising the damaged region of themeniscus 142 or 144 under the arthroscope 22 can be considered asfollows.

By use of the treatment system 10, the surgeon can perform a series oftreatment of excising the synovial membrane 134 and excising the damagedregion of the meniscus 142 or 144 with the treating portion 68 of theultrasonic treatment device 32 while the one ultrasonic treatment device32 is disposed as it is in the second cannula 18 b. Consequently, duringthe surgical treatment, the surgeon does not need to replace thetreatment device 32 disposed in the joint cavity 136, and hence surgicaltreatment time can be shortened.

The probe 66 of the ultrasonic treatment device 32 can be formed intothe suitable shape, and the treating portion 68 can be formed to besmaller than the shaver or the abrader burr. Consequently, in thetreatment in which the ultrasonic treatment device 32 is used, a movablerange to the second cannula 18 b can be increased, and treatment regionssuch as the anterior horn of the medial meniscus 142 and the posteriorhorns and posterior nodes of the medial meniscus 142 and the lateralmeniscus 144 can more easily be approached as compared with the casewhere the shaver is used. Additionally, in the treatment of theultrasonic treatment device 32, the more precise and smoother treatedsurface can be formed than in the case where the shaver or the abraderburr is used. Consequently, for example, when the surgeon performs thetreatment by use of the ultrasonic treatment device 32 and then thepatient bends and stretches the knee joint 100 to move the meniscus 142or 144, the meniscus can be prevented from being stuck on the femur 112or the tibia 114, which can contribute to the smooth joint movement.

In addition, the surgeon uses the ultrasonic treatment device 32 andhence does not have to use a high frequency device (an RF device). Asshown in FIG. 9C, when the treatment is performed by using the highfrequency device, there is the fear that the surface (an inferior boneof the cartilage) is invaded by heat. On the other hand, as shown inFIG. 9A, in the case where the ultrasonic treatment device 32 is used,for example, the cartilage 114 a of the tibia 114 under the meniscus 142or 144 is less invaded by heat, and thermal necrosis is prevented frombeing caused to the cartilage 114 a in the treated surface excised bythe treating portion 68, as compared with the case where the highfrequency device is used.

Next, there will be described a method in which the surgeon uses thetreatment system 10 mentioned above to perform a surgical treatment ofexcising a damaged region of the cartilage 112 a under the arthroscope22 to the patient who has the damaged region in the spherical cartilage112 a. Here, together with the removal of the synovial membrane 134 andthe treatment of the damaged region of the meniscus 142 or 144, there isdescribed a method of removing a denatured cartilage in a case whereosteochondritis dissecans (OCD) occur.

The knee joint 100 might cause the osteochondritis dissecans. Thesurgeon confirms the osteochondritis dissecans by use of MRI or thelike. Degrees of progress of the osteochondritis dissecans are indicatedas, for example, grades of ICRS (International Cartilage RepairSociety), i.e., Grade 0 (Normal), Grade 1 (Stable, continuity: Softenedarea covered by intact cartilage), Grade 2 (Partial discontinuity,stable on probing), Grade 3 (Complete discontinuity, “dead in situ”, notdislocated), Grade 4 (Dislocated fragment, loose within the bed or emptydefect. >10 mm in depth is B-subgroup). In the knee joint 100, thecartilages 112 a are damaged in, for example, the medial condyle 122 andthe lateral condyle 124 of the femur 112 due to the osteochondritisdissecans.

There are prepared the instrument to form the portals 102 and 104 in theknee joint 100, and an instrument for use in a surgical treatment ofexcising the cartilage and the bone. It is to be noted that the treatingportion 68 of the ultrasonic treatment device 32 is formed into thesuitable shape, e.g., the hook type.

The surgeon disposes the distal end of the arthroscope 22 in the jointcavity 136 of the knee joint 100 of the patient through the firstcannula 18 a. The surgeon fills the joint cavity 136 of the knee joint100 of the patient with the saline (the perfusion liquid) by use of theperfusion device 16. In this state, the surgeon suitably observes theinside of the joint cavity 136 of the knee joint 100 of the right kneeby use of the arthroscope 22. Further, the surgeon disposes the damagedregion of the meniscus 142 or 144 in the view field of the arthroscope22 to confirm the damage. Additionally, the surgeon confirms theinflammation of the synovial membrane 134 in the joint capsule 130 ofthe knee joint 100.

The surgeon disposes the treating portion 68 of the ultrasonic treatmentdevice 32 in the joint cavity 136 of the knee joint 100 of the patientthrough the second cannula 18 b. In a case where a region that causesinflammation is present in the synovial membrane 134 of the jointcapsule 130 confirmed with the arthroscope 22, the surgeon excises theinflamed region from the synovial membrane 134 with the treating portion68 of the ultrasonic treatment device 32 to which the ultrasonicvibration is transmitted, while observing the inflamed region with thearthroscope 22. Similarly, the ultrasonic vibration is transmitted tothe same treating portion 68 of the ultrasonic treatment device 32 toexcise the damaged region of the meniscus 142 or 144. That is, whennecessary, the inflamed region of the synovial membrane 134 or thedamaged region of the meniscus 142 or 144 is excised as described above,or when possible, the damaged region of the meniscus 142 or 144 issutured and treated.

For example, when the cartilage 112 a attached to the medial condyle 122of the femur 112 is damaged, the surgeon confirms the grade of theosteochondritis dissecans with the arthroscope 22. By use of thearthroscope 22, the surgeon confirms whether a part of the cartilage 112a is softened (Grade 1), whether laceration such as partial tear ispresent in a part of the cartilage 112 a (Grade 2), whether a part ofthe cartilage 112 a is discontinued from a bone (the medial condyle 122of the femur 112) to which the cartilage 112 a adheres (Grade 3), orwhether a bone cartilage piece is liberated and the bone (the medialcondyle 122 of the femur 112) to be hidden behind the cartilage 112 a isexposed (Grade 4), to judge the grade. Additionally, in each of Grades 1to 4, presence/absence of the bone spurs and presence/absence ofhardened regions are confirmed to the medial condyle 122 and the lateralcondyle 124 of the femur 112.

Further, as shown in FIG. 10A, the treating portion 68 of the ultrasonictreatment device 32 is brought into contact with the treatment objectregion of the cartilage 112 a while observing the treatment objectregion always disposed in the view field of the arthroscope 22. In thisstate, the switch 36 is operated to suitably perform the treatment tothe treatment object region by use of the ultrasonic vibration. At thistime, as shown in FIG. 10B, the surgeon can easily form the treatedsurface by the treating portion 68 to which the ultrasonic vibration ofthe ultrasonic treatment device 32 is transmitted, as the smooth surfacewithout forming any corner portions therein, by suitably moving thetreating portion 68 in accordance with the movement of the probe 66 inthe axial direction. As shown in FIG. 10B, when the treatment objectregion of the cartilage 112 a is removed, a dented region having asubstantially circular vertical cross section is formed, and there aresmoothly continued the removed surface 146 from which the treatmentobject region of the cartilage 112 a is removed and the non-removedsurface 148 adjacent to the removed surface 146. In consequence, theregion treated with the treating portion 68 of the ultrasonic treatmentdevice 32 by the surgeon is hard to be stuck on another region.

Here, when the surgeon judges that a condition of a part of thecartilage 112 a is Grade 2, as shown in FIG. 10A, the treating portion68 of the ultrasonic treatment device 32 is faced to a torn region (atreatment object region) 112 b of the cartilage 112 a. Further, the tornregion of the cartilage 112 a is removed by moving the treating portion68 along the axial direction of the probe 66 while transmitting theultrasonic vibration to the treating portion 68 of the ultrasonictreatment device 32. In addition, the bone spur formed in Grade 2 isremoved by transmitting the ultrasonic vibration to the treating portion68 of the ultrasonic treatment device 32 under the arthroscope 22 asdescribed above. Also at this time, the treatment is performed withoutleaving any corner portions in treated regions of the cartilage 112 aand the medial condyle 122 of the femur 112.

When the surgeon judges that the condition of a part of the cartilage112 a is Grade 3, as shown in FIG. 10A, the treating portion 68 of theultrasonic treatment device 32 is faced to the torn region (thetreatment object region) 112 b of the cartilage 112 a and a torn regionof the medial condyle 122 of the femur 112. Further, the torn region 112b of the cartilage 112 a and the torn region of the medial condyle 122of the femur 112 are removed together with the bone spurs formed in themedial condyle 122 of the femur 112 and the like, by moving the treatingportion 68 along the axial direction of the probe 66 while transmittingthe ultrasonic vibration to the treating portion 68 of the ultrasonictreatment device 32. Also at this time, the treatment is performedwithout leaving any corner portions in the treated regions of thecartilage 112 a and the medial condyle 122 of the femur 112.

When the surgeon judges that the condition of a part of the cartilage112 a is Grade 4, the torn region (the treatment object region) 112 b ofthe cartilage 112 a shown in FIG. 10A might peel from the medial condyle122 of the femur 112. In this case, when the inferior bone (the medialcondyle 122 of the femur 112) of the cartilage 112 a undergoes necrosisdue to an interruption in circulation of blood or the like, the bonecartilage piece separates to be liberated as a loose body in the jointcapsule 130. In addition, the loose body might be separated also fromthe cartilage 112 a into the joint capsule 130. In such a case, thetreating portion 68 of the ultrasonic treatment device 32 is opposed tothe torn region 112 b of the cartilage 112 a and the torn region of themedial condyle 122 of the femur 112. Further, the torn region 112 b ofthe cartilage 112 a and the torn region of the medial condyle 122 of thefemur 112 are removed together with the osteophyte formed in the medialcondyle 122 of the femur 112, by moving the treating portion 68 alongthe axial direction of the probe 66 while transmitting the ultrasonicvibration to the treating portion 68 of the ultrasonic treatment device32. Also at this time, the treatment is performed without leaving anycorner portions in the treated regions of the cartilage 112 a and themedial condyle 122 of the femur 112. It is to be noted that the regionliberated from the cartilage 112 a is sucked or curetted to be removed.Further, excision of the deformed cartilage 112 a, removal of thecuretted or liberated cartilage piece, and grafting of the cartilage 112a′are carried out. For example, when the bone cartilage piece isgrafted, a region to be grafted needs to be dissected. In this case, theultrasonic vibration is transmitted to the treating portion 68 of theultrasonic treatment device 32 to smoothly continue the removed surface146 and the non-removed surface 148 adjacent to the removed surface 146as shown in FIG. 10B, thereby carrying out the dissection. Further, thebone cartilage piece is fixed by a known method.

Thus, in accordance with the condition, the treating portion 68 is movedalong the axial direction of the probe 66 while transmitting theultrasonic vibration to the treating portion 68 of the ultrasonictreatment device 32, to suitably dissect the cartilage 112 a. Inaddition, the ultrasonic vibration is transmitted to the treatingportion 68 of the same ultrasonic treatment device 32, to remove thebone spur. Also when the bone spur is removed, the treatment isperformed without leaving any corner portions and the smooth surface isformed without forming any corner portions in the same manner as shownin FIG. 10B.

Here, there has been described the example where the cartilage 112 a ofthe femur 112 and the femur 112 are treated, but the inferior cartilage118 a (see FIG. 4) of the patella 118 in chondromalacia patellae cansimilarly be treated.

As described above, the technique of removing the damaged region 112 bof the cartilage 112 a under the arthroscope 22 can be considered asfollows.

By use of the treatment system 10, the surgeon can perform a series oftreatment of removing the cartilage 112 a and the treatment objectregion of the femur 112 with the treating portion 68 of the treatmentdevice 32 while the one ultrasonic treatment device 32 is disposed as itis in the second cannula 18 b. Consequently, by use of the treatmentsystem 10, the surgeon can perform a series of treatment of excising thesynovial membrane 134, excising the damaged region of the meniscus 142or 144 and removing the cartilage 112 a and the treatment object regionof the femur 112 with the treating portion 68 of the treatment device 32while the one ultrasonic treatment device 32 is disposed as it is in thesecond cannula 18 b.

Further, the surgeon has heretofore replaced and used differentinstruments to the portal 104 by, for example, using the shaver or thelike in a smoothening treatment of the cartilage 112 a and using theabrader burr or the like in the smoothening treatment of the femur 112,the tibia 114 or the patella 118. When the cartilage 112 a and thetreatment object region 112 b of the femur 112 are removed, theultrasonic treatment device 32 does not have to be replaced to theportal 104. These treatments can be performed with the one ultrasonictreatment device 32. Consequently, during the surgical treatment, thesurgeon does not have to replace the treatment device 32 disposed in thejoint cavity 136, and hence the surgical treatment time can beshortened.

The probe 66 of the ultrasonic treatment device 32 can be formed intothe suitable shape, and the treating portion 68 can be formed to besmaller than the shaver or the abrader burr. Consequently, in thetreatment in which the ultrasonic treatment device 32 is used, themovable range can be increased, and treatment regions such as backsurfaces or the like of the medial condyle 122 and the lateral condyle124 of the femur 112 and a treatment region of a joint surface (aninferior surface) of the patella 118 can more easily be approached ascompared with the case where the shaver or the abrader burr is used.Additionally, in the treatment of the ultrasonic treatment device 32,the more precise and smoother treated surface can be formed than in thecase where the shaver or the abrader burr is used. Consequently, forexample, when the surgeon performs the treatment by use of theultrasonic treatment device 32 and then the patient bends and stretchesthe knee joint 100 to move the femur 112, the tibia 114 and the patella118, the femur 112, the tibia 114 and the patella 118 can be preventedfrom being stuck on one another, which can contribute to the smoothjoint movement.

The abrader burr abrades the bone (the bone spur) that is the hardtissue by the periaxial rotation, and hence loads that act on theabrader burr increase in a case where the bone is abraded. Consequently,the abrader burr might noticeably entirely be vibrated by the loads ontothe treating portion. On the other hand, the treating portion 68 of theultrasonic treatment device 32 is not periaxially rotated but the bonecan be resected only by moving (vibrating) the treating portion in theaxial direction of the probe 66. Consequently, loads that act on thehousing 62 or the like through the treating portion 68 are small in acase where the bone is resected by the treating portion 68. Inconsequence, the ultrasonic treatment device 32 inserted into the jointcavity 136 of the knee joint 100 through the portal 104 does notnoticeably vibrate. That is, in the case where the bone is resected bythe treating portion 68, leaping of the treating portion 68 is notcaused by a rotary motion as in the abrader burr, and hence damages ofthe peripheral tissue can be decreased.

In addition, the surgeon uses the ultrasonic treatment device 32 andhence does not have to use the high frequency device. When the treatmentis performed by using the high frequency device, there is the fear thatthe surface (the bone under the cartilage) is invaded by heat. On theother hand, when the ultrasonic treatment device 32 is used, normalregions of the cartilages 112 a, 114 a and 118 a of the femur 112, thetibia 114 and the patella 118 are less invaded by heat, and the thermalnecrosis is prevented from being caused to the cartilages 112 a, 114 aand 118 a.

Next, there will be described a method in which the surgeon uses thetreatment system 10 mentioned above to excise the anterior cruciateligament 152 under the arthroscope 22 to the patient who has the damagedregion in the anterior cruciate ligament 152, and a reconstructingmethod of the anterior cruciate ligament 152. Additionally, here, thereare treated the inflammation of the synovial membrane 134, the damagedregion of the meniscus 142 or 144 and the osteochondritis dissecans(OCD) which often occur together with the damage of the anteriorcruciate ligament 152.

There are prepared an instrument to form the portals 102 and 104 in theknee joint 100, and an instrument for use in a surgical treatment ofreconstructing the anterior cruciate ligament 152. It is to be notedthat the treating portion 68 of the ultrasonic treatment device 32 isformed into a suitable shape such as the hook type.

When the anterior cruciate ligament 152 is reconstructed, the surgeonfirst collects a tendon to be implanted from a hamstring (asemitendinosus muscle, or a gracilis muscle), a patellar tendon or thelike and prepares a graft 156 (see FIG. 14) that replaces the anteriorcruciate ligament 152. The surgeon judges a position of the patient fromwhich the tendon to be implanted is to be collected to prepare the graft156, depending on, for example, a patient's condition, an activity planfrom now on, or the like. Various ways to consider selection of thetendon to be implanted are present, but are known, and hencedescriptions thereof are omitted here.

The surgeon disposes the distal end of the arthroscope 22 in the jointcavity 136 of the knee joint 100 of the patient through the firstcannula 18 a. The surgeon uses the perfusion device 16 to fill the jointcavity 136 of the knee joint 100 of the patient with the saline whilesucking the inside of the joint cavity. In this state, the surgeonsuitably observes the inside of the joint cavity 136 of the knee joint100 by use of the arthroscope 22.

The surgeon disposes the treating portion 68 of the ultrasonic treatmentdevice 32 in the joint cavity 136 of the knee joint 100 of the patientthrough the second cannula 18 b. As required, the surgeon excises theinflamed region of the synovial membrane 134 and the damaged region ofthe meniscus 142 or 144 as described above. In addition, the surgeonappropriately treats regions to which the osteochondritis dissecans arecaused in the femur 112, the tibia 114 and the patella 118.

The arthroscope 22 passed through the first cannula 18 a is moved to theposterior side of the knee joint 100, to confirm a remaining region ofthe anterior cruciate ligament 152 to the cartilage 112 a of the lateralcondyle 124 of the femur 112. As shown in FIG. 11A, the surgeon confirmsa footprint region (an anatomical position to which the anteriorcruciate ligament 152 adheres) 162 of the anterior cruciate ligament 152on a femur 112 side with the arthroscope 22, and also confirms aresident ridge (bone ridge) 162 a (see FIG. 11B) of the start region ofthe anterior cruciate ligament 152. Further, the treatment of theremaining region of the anterior cruciate ligament 152 to the cartilage112 a on the femur 112 side is performed with the ultrasonic treatmentdevice 32. That is, as shown in FIG. 11A, the ridge 162 a of the startregion of the anterior cruciate ligament 152 is dissected in a stateshown in FIG. 11B, by moving the treating portion 68 along the axialdirection of the probe 66 while transmitting the ultrasonic vibration tothe treating portion 68 of the ultrasonic treatment device 32.Specifically, as shown in FIG. 11A, the treating portion 68 of theultrasonic treatment device 32 is disposed to abut on the remainingregion of the anterior cruciate ligament 152, and the treating portion68 is moved along the axial direction of the probe 66 while transmittingthe ultrasonic vibration to the treating portion 68 of the ultrasonictreatment device 32, thereby resecting the remaining region. At thistime, the treating portion 68 of the ultrasonic treatment device 32 cansimultaneously cut off a soft tissue of the remaining region of theanterior cruciate ligament 152 and the hard tissue of the femur 112. Inconsequence, the ultrasonic treatment device 32 does not have to bereplaced to the second cannula 18 b.

As shown in FIG. 11B, a position of the footprint region 162 at whichthe start region of the removed anterior cruciate ligament 152 has beenpresent is confirmed with the arthroscope 22 again. This position of thefootprint region 162 is to be a position of one end of a tunnel 166 onthe femur 112 side. To clarify the position of the one end of the tunnel166, a part of the footprint region 162 of the anterior cruciateligament 152 of the femur 112 is resected with the treating portion 68of the ultrasonic treatment device 32 to which the ultrasonic vibrationis transmitted, to form a concave hole 164 of a suitable depth shown inFIG. 11C. The surgeon uses the concave hole 164 as an auxiliary hole (aguiding hole) to form the tunnel 166 at a desirable position by anafter-mentioned drill. In addition, the surgeon uses the concave hole164 as a marking. The concave hole 164 is formed from a region to whichthe ligament 152 has adhered (the footprint region) toward a lateralsurface of the lateral condyle 124 of the femur 112.

The probe 66 of the ultrasonic treatment device 32 can be formed intothe suitable shape, and the treating portion 68 can be formed to besmaller than the shaver or the abrader burr. Consequently, in thetreatment in which the ultrasonic treatment device 32 is used, themovable range to the cannula 18 b can be increased, and a treatmentregion such as the footprint region 162 in which the start region of theanterior cruciate ligament 152 of the femur 112 has been present canmore easily be approached as compared with the case where the shaver orthe abrader burr is used. Additionally, the treating portion 68 of theultrasonic treatment device 32 can simultaneously resect a remainingligament and the femur 112. Consequently, when the surgeon performs thetreatment by use of the ultrasonic treatment device 32 according to thisembodiment, inserting and removing of the treatment device through thesecond cannula 18 b, e.g., replacing of the shaver to remove the softtissue with the abrader burr to remove the hard tissue can beeliminated.

Afterward, as shown in FIG. 12A, the surgeon moves the arthroscope 22passed through the first cannula 18 a to an anterior side of the kneejoint 100, to confirm the remaining region of the anterior cruciateligament 152 to the cartilage 114 a on a tibia 114 side in the samemanner as in the femur 112 side. As shown in FIG. 12A, the surgeonconfirms a footprint region (an anatomical position to which theanterior cruciate ligament 152 adheres) 172 of the anterior cruciateligament 152 on the tibia 114 side with the arthroscope 22. Further, atreatment of the remaining region of the anterior cruciate ligament 152to the cartilage 114 a on the tibia 114 side is performed with theultrasonic treatment device 32. That is, as shown in FIG. 12A, the endregion of the anterior cruciate ligament 152 is dissected in a stateshown in FIG. 12B, by moving the treating portion 68 along the axialdirection of the probe 66 while transmitting the ultrasonic vibration tothe treating portion 68 of the ultrasonic treatment device 32.Specifically, as shown in FIG. 12A, the treating portion 68 of theultrasonic treatment device 32 is disposed to abut on the remainingregion of the anterior cruciate ligament 152, and the treating portion68 is moved along the axial direction of the probe 66 while transmittingthe ultrasonic vibration to the treating portion 68 of the ultrasonictreatment device 32, thereby resecting the remaining region. At thistime, the treating portion 68 of the ultrasonic treatment device 32 cansimultaneously cut off the soft tissue of the remaining region of theanterior cruciate ligament 152 and the hard tissue of the tibia 114. Inconsequence, the ultrasonic treatment device 32 does not have to bereplaced to the second cannula 18 b.

As shown in FIG. 12B, a position of the footprint region 172 at whichthe end region of the removed anterior cruciate ligament 152 has beenpresent is confirmed with the arthroscope 22 again. This position of thefootprint region 172 is to be a position of one end of a tunnel 176 onthe tibia 114 side. To clarify the position of the one end of the tunnel176, the footprint region 172 of the anterior cruciate ligament 152 ofthe tibia 114 is resected with the treating portion 68 of the ultrasonictreatment device 32 to which the ultrasonic vibration is transmitted, toform a concave hole 174 of a suitable depth shown in FIG. 12C. Thesurgeon uses the concave hole 174 as an auxiliary hole (a guiding hole)to form the tunnel 176 at a desirable position by the after-mentioneddrill. In addition, the surgeon uses the concave hole 174 as a marking.The concave hole 174 is formed from the region to which the ligament 152has adhered (the footprint region) toward a medial surface of a roughsurface of the tibia 114.

The ultrasonic treatment device 32 is removed from the second cannula 18b after these treatments are ended.

Afterward, as shown in FIG. 13A, the surgeon forms a small hole in thetibia 114 by use of, for example, a wire-shaped first drill, andenlarges a diameter of the hole by a second drill having a largerdiameter in accordance with a cross section of the graft 156 to form thetunnel 176 in the tibia 114. Similarly, as shown in FIG. 13B, the tunnel166 is formed in the femur 112.

Here, for the purpose of forming the tunnel 166, an instrument 72 thatguides the drill (not shown) is used. The instrument 72 has a main body74 and a guiding tube 76 that guides the drill toward one end 74 a ofthe main body 74.

The surgeon forms the concave hole 164 at one end of a position to formthe bone tunnel 166 in the femur 112 with the treating portion 68 of theultrasonic treatment device 32. Consequently, for example, the one end74 a of the main body 74 of the instrument 72 that guides the drill toform the bone tunnel 166 is fixed to the concave hole 164 through theportal 104 from which the second cannula 18 b is pulled out, immediatelybefore the bone tunnel 166 is formed.

The guiding tube 76 of the instrument 72 is supported at the other end74 b of the main body 74. At this time, in the main body 74, a distalend 76 a of the guiding tube 76 is directed toward the one end 74 a ofthe main body 74. That is, the distal end 76 a of the guiding tube 76 isdisposed toward the concave hole 164. Further, the surgeon passes theguiding tube 76 supported at the other end 74 b of the main body 74, ina direction from the lateral side of skin of the right knee toward theone end 74 a of the main body 74. The distal end 76 a of the guidingtube 76 is disposed to abut on a lateral side of the lateral condyle 124of the femur 112. It is to be noted that, when the concave hole 164 isused as a supporting point, the distal end 76 a of the guiding tube 76is passed from a suitable position of the lateral side of the skin ofthe right knee, to be supported at a suitable position of the lateralside of the lateral condyle 124 of the femur 112. Further, the unshowndrill is guided from a proximal end 76 b of the guiding tube 76 towardthe distal end 76 a of the guiding tube 76. The bone tunnel 166 isformed by the drill toward the one end 74 a of the main body 74 from astate where the distal end of the drill is disposed to abut on the outerside of the lateral condyle 124 of the femur 112. In consequence, thebone tunnel 166 is formed from the outer side of the skin toward theconcave hole 164. At this time, the one end 74 a of the main body 74 ofthe instrument 72 is applied to the concave hole 164 of the femur 112,and hence one end of the bone tunnel 166 is easily formed at ananatomically correct position to the femur 112. That is, the concavehole 164 of the femur 112 is used as the supporting point to form thebone tunnel (tunnel) 166 between the concave hole 164 of the femur 112and the outer surface of the lateral condyle 124 of the femur 112.Afterward, the second drill having a larger diameter than the firstdrill is moved along the first drill to suitably enlarge the tunnel 166in accordance with an outer diameter of the graft 156.

Here, for the purpose of forming the bone tunnel 176, an instrument 82that guides the drill (not shown) is used. The instrument 82 has a mainbody 84 and a guiding tube 86 that guides the drill toward one end 84 aof the main body 84.

In addition, the surgeon forms the concave hole 174 at one end of aposition to form the bone tunnel 176 in the tibia 114 with the treatingportion 68 of the ultrasonic treatment device 32. Consequently, forexample, the one end 84 a of the main body 84 of the instrument 82 thatguides the drill to form the tunnel 176 is fixed to the concave hole 174through the portal 104 from which the second cannula 18 b is pulled out,immediately before the bone tunnel 176 is formed.

The guiding tube 86 of the instrument 82 is supported at the other end84 b of the main body 84. At this time, in the main body 84, a distalend 86 a of the guiding tube 86 is directed toward the one end 84 a ofthe main body 84. That is, the distal end 86 a of the guiding tube 86 isdisposed toward the concave hole 174. Further, the surgeon passes theguiding tube 86 supported at the other end 84 b of the main body 84, ina direction from the lateral side of the skin of the right knee towardthe one end 84 a of the main body 84. The distal end 86 a of the guidingtube 86 is disposed to abut on a rough surface of a front surface of thetibia 114. It is to be noted that, when the concave hole 174 is used asthe supporting point, the distal end 86 a of the guiding tube 86 ispassed from a suitable position of the lateral side of the skin of theright knee, to be supported at a suitable position of the outer side ofthe rough surface of the tibia 114. Further, the unshown drill is guidedfrom a proximal end 86 b of the guiding tube 86 toward the distal end 86a of the guiding tube 86. The bone tunnel 176 is formed by the drilltoward the one end 84 a of the main body 84 from a state where thedistal end of the drill is disposed to abut on the lateral side of therough surface of the tibia 114. In consequence, the bone tunnel 176 isformed from the lateral side of the skin toward the concave hole 174. Atthis time, the one end 84 a of the main body 84 of the instrument 82 isapplied to the concave hole 174 of the tibia 114, and hence one end ofthe bone tunnel 176 is easily formed at an anatomically correct positionto the tibia 114. That is, the concave hole 174 of the tibia 114 is usedas the supporting point to form the bone tunnel 176 between the concavehole 174 of the tibia 114 and the rough surface of the tibia 114.Afterward, the second drill having a larger diameter than the firstdrill is moved along the first drill, to suitably enlarge the bonetunnel 176 in accordance with the outer diameter of the graft 156.

For example, when a position to which an end of the anterior cruciateligament 152 has adhered is dissected by using the abrader burr, it hasbeen difficult to form the concave hole due to the problem ofaccessibility or the problem that treatment time is lengthened. Here,the concave holes 164 and 174 are suitably formed by using theultrasonic treatment device 32, and hence the one end of each of theknown instruments 72 and 82 that guide the first drill to form the bonetunnels 166 and 176 can exactly be positioned. Consequently, the bonetunnels 166 and 176 can exactly be prepared more easily than before, ina state where the instrument is matched with each of the ends (the startregion and the end region) of the anterior cruciate ligament 152 beforedamaged, to the femur 112 and the tibia 114.

The instruments 72 and 82 and the like are removed, and then, as shownin FIG. 14, the graft 156 prepared in advance is inserted through thebone tunnels 166 and 176 into the joint cavity 136 of the knee joint100, to fix the one end of the graft 156 to the lateral side of thelateral condyle 124 of the femur 112 and to fix the other end of thegraft to the rough surface of the tibia 114. At this time, the graft 156may be inserted from the femur 112 side toward the tibia 114 side, ormay be inserted from the tibia 114 side toward the femur 112 side. Oneof the one end and the other end of the graft 156 is fixed with a fixingtool 92.

As described above, the technique of excising the damaged region of theanterior cruciate ligament 152 under the arthroscope 22 and thetechnique of reconstructing the anterior cruciate ligament 152 can beconsidered as follows.

By use of the treatment system 10, a series of treatment of removing thedamaged anterior cruciate ligament 152 and exposing the footprintregions 162 and 172 can be performed with the treating portion 68 of thetreatment device 32, while the one ultrasonic treatment device 32 isdisposed as it is in the second cannula 18 b. The surgeon has heretoforereplaced and used different instruments to the portal 104 by, forexample, using the shaver or the like in a removing treatment of theremaining ligament of the anterior cruciate ligament 152 and using theabrader burr or the like in the smoothening treatment (the exposingtreatment) of the footprint regions 162 and 172 of the hard tissue. Whenthe remaining ligament of the anterior cruciate ligament 152 and thetreatment object regions of the footprint regions 162 and 172 areremoved, the ultrasonic treatment device 32 does not have to be replacedto the portal 104. These treatments can be performed with the oneultrasonic treatment device 32. Consequently, during the surgicaltreatment, the surgeon does not have to replace the treatment device 32disposed in the joint cavity 136, and hence the surgical treatment timecan be shortened.

In addition, the footprint regions 162 and 172 are dissected, andsimultaneously, the concave holes 164 and 174 can be formed with thetreating portion 68 of the ultrasonic treatment device 32 withoutreplacing the tool. In consequence, the one end of each of theinstruments 72 and 82 to suitably form the bone tunnels 166 and 176 caneasily be positioned to the concave holes 164 and 174.

When the bone tunnels 166 and 176 are formed by utilizing the concaveholes 164 and 174 prepared by using an ultrasonic output under thearthroscope 22, shift of the one end of each of the instruments 72 and82 can be prevented, and hence the bone tunnels 166 and 176 can moreexactly be prepared at the correct positions. At this time, the concaveholes 164 and 174 are prepared and the concave holes 164 and 174 areutilized, and hence the bone tunnels 166 and 176 can be formed at thecorrect positions without necessarily using an X-ray.

The probe 66 of the ultrasonic treatment device 32 can be formed intothe suitable shape, and the treating portion 68 can be formed to besmaller than the shaver or the abrader burr. Consequently, in thetreatment in which the ultrasonic treatment device 32 is used, themovable range to the cannula 18 b can be increased, and a treatmentregion such as the rear side of the knee joint 100 can more easily beapproached as compared with the case where the shaver or the abraderburr is used. Additionally, in the treatment of the ultrasonic treatmentdevice 32, the more precise and smoother treated surface can be formedthan in the case where the shaver or the abrader burr is used.Consequently, when the surgeon performs the treatment by use of theultrasonic treatment device 32 and then the patient bends and stretchesthe knee joint 100 to move the femur 112, the tibia 114 and the patella118, the femur 112, the tibia 114 and the patella 118 can be preventedfrom being stuck on one another, which can contribute to the smoothjoint movement.

The abrader burr abrades the bone that is the hard tissue by theperiaxial rotation, and hence the loads that act on the abrader burrincrease in a case where the bone is abraded. Consequently, the abraderburr might noticeably entirely be vibrated by the loads onto thetreating portion. On the other hand, the treating portion 68 of theultrasonic treatment device 32 is not periaxially rotated but the bonecan be resected only by moving (vibrating) the treating portion in theaxial direction of the probe 66. Consequently, the loads that act on thehousing 62 or the like through the treating portion 68 are small in acase where the bone is resected by the treating portion 68. Inconsequence, the ultrasonic treatment device 32 inserted into the jointcavity 136 of the knee joint 100 through the portal 104 does notnoticeably vibrate. That is, in the case where the bone is resected bythe treating portion 68, the leaping of the treating portion 68 is notcaused by the rotary motion as in the abrader burr, and hence thedamages of the peripheral tissue can be decreased.

In addition, the surgeon uses the ultrasonic treatment device 32 andhence does not have to use the high frequency device. When the treatmentis performed by using the high frequency device, there is the fear thatthe surface is invaded by heat. On the other hand, when the ultrasonictreatment device 32 is used, the normal regions of the cartilages 112 aand 114 a of the femur 112 and the tibia 114 are less invaded by heat,and the thermal necrosis is prevented from being caused to thecartilages 112 a and 114 a.

It is to be noted that the concave holes 164 and 174 do not necessarilyhave to be formed. When the concave hole 164 is not formed, one end ofthe instrument 72 that guides the drill to form the bone tunnel 166 isdisposed in the footprint region 162 of the anterior cruciate ligament152 of the femur 112, to form the bone tunnel 166 in the femur 112. Thatis, the footprint region 162 is used as the supporting point in place ofthe concave hole 164, to form the bone tunnel 166 in the femur 112 byuse of the instrument 72. Similarly, when the concave hole 174 is notformed, one end of the instrument 82 that guides the drill to form thebone tunnel 176 is disposed in the footprint region 172 of the anteriorcruciate ligament 152 of the tibia 114, to form the bone tunnel 176 inthe tibia 114. That is, the footprint region 172 is used as thesupporting point in place of the concave hole 174, to form the bonetunnel 176 in the tibia 114 by use of the instrument 82.

Here, an order to prepare the bone tunnels 166 and 176 is described inorder of the femur 112 and the tibia 114, but, needless to say, theorder may be reversed, i.e., the order may be the tibia 114 and then thefemur 112.

In addition, here, there is described the example where the anteriorcruciate ligament 152 is reconstructed, but also when the posteriorcruciate ligament 154 is reconstructed, the treating portion 68 of theultrasonic treatment device 32 can similarly simultaneously cut off thesoft tissue of the remaining region of the posterior cruciate ligamentand the hard tissue of the femur 112. In consequence, the footprintregion of the posterior cruciate ligament 154 on the femur 112 side caneasily be confirmed by using the arthroscope 22. Similarly, the treatingportion 68 of the ultrasonic treatment device 32 can simultaneously cutoff the soft tissue of the remaining region of the posterior cruciateligament 154 and the hard tissue of the tibia 114. In consequence, thefootprint region of the posterior cruciate ligament 154 on the tibia 114side can easily be confirmed by using the arthroscope 22. In addition,the concave holes 164 and 174 can easily be formed under the arthroscope22 by moving the treating portion 68 along the axial direction of theprobe 66 while transmitting the ultrasonic vibration to the treatingportion 68 of the ultrasonic treatment device 32, to the footprintregions of the posterior cruciate ligaments 154 of the femur 112 and thetibia 114 in the same manner as in the footprint regions 162 and 172 ofthe anterior cruciate ligament 152.

Shoulder Joint

When a shoulder joint 200 is treated, for example, a treatment system201 shown in FIG. 15A and FIG. 15B is used.

When a shoulder joint 200 is treated, for example, a treatment system201 shown in FIG. 15B is used. The treatment system 201 includes atreatment apparatus (treatment device) 202, an arthroscope device 203,and a perfusion device 16.

The arthroscope device 203 has an arthroscope 204, an image processingunit 205 and a display unit 206.

The arthroscope 204 includes an inserting portion 207 and a holdingportion 208. In a treatment in which this arthroscope is used, a distalend of the inserting portion 207 is inserted into the shoulder joint200. The holding portion 208 is connected to one end of a universal cord211. The other end of the universal cord 211 is connected to the imageprocessing unit 205, i.e., an image processor or the like. The imageprocessing unit 205 is electrically connected to the display unit 206,i.e., the monitor or the like.

At the distal end of the inserting portion 207, an imaging element isdisposed, and the imaging element is electrically connected to the imageprocessing unit 205. The image acquired by the imaging element isprocessed by the image processing unit 205 and displayed in the displayunit 206. It is to be noted that the arthroscope 204 is connected to anunshown light source unit, and a subject is irradiated with lightemitted from the light source unit.

The perfusion device 16 includes a bag-shaped liquid source 42 thatcontains a perfusion liquid such as saline, a perfusion pump unit 44, aliquid supply tube 46 whose one end is connected to the liquid source42, a liquid discharge tube 48, and a suction bottle 50 connected to oneend of the liquid discharge tube 48. The suction bottle 50 is connectedto a suction source attached to a wall of an operating room. In theperfusion pump unit 44, the perfusion liquid can be supplied from theliquid source 42 by a liquid supply pump 44 a. Additionally, in theperfusion pump unit 44, suction/suction stop of the perfusion liquid inthe joint cavity 136 of the shoulder joint 200 to the suction bottle 50can be switched by opening/closing a pinching valve 44 b as a liquiddischarge valve.

The other end of the liquid supply tube 46 that is a liquid supply tubepath is connected to a first cannula 18 a. In consequence, the perfusionliquid can be supplied into the joint cavity 136 of the joint 200 viathe first cannula 18 a. The other end of the liquid discharge tube 48that is a liquid discharge tube path is connected to the first cannula18 a. In consequence, the perfusion liquid can be discharged from thejoint cavity 136 of the joint 200 via the first cannula 18 a. It is tobe noted that, needless to say, the other end of the liquid dischargetube 48 may be connected to a second cannula 18 b, so that the perfusionliquid can be discharged from the joint 200.

It is to be noted that, here, the perfusion liquid can be supplied anddischarged through the first cannula 18 a, but a function that iscapable of supplying and/or discharging the perfusion liquid may beimparted to, for example, the arthroscope 204. Similarly, the functionthat is capable of supplying and/or discharging the perfusion liquid maybe imparted to a hand piece 212. In addition, a function that is capableof supplying and discharging the perfusion liquid through the secondcannula 18 b may be imparted. Furthermore, the perfusion liquid may besupplied and discharged from separate portals.

The treatment device 202 includes the hand piece 212, a power sourceunit 213, and a cable 214 connecting the hand piece 212 to the powersource unit 213. The treatment device 202 is one example of theultrasonic device. The power source unit 213 has an energy controlsection 219, and an ultrasonic current supply section 220 to becontrolled by the energy control section 219, thereby supplying power toa vibration generating section 215.

The hand piece 212 includes a housing 210 constituting an outer shell,the vibration generating section 215 housed in the housing 210, arod-like ultrasonic probe 216 connected to the vibration generatingsection 215, a hollow (cylindrical) sheath 217 that covers a peripheryof the ultrasonic probe 216 to protect the ultrasonic probe 216, a knob218 rotatably attached to the housing 210, and an energy input button(switch) 221 disposed in the housing 210.

The housing 210 is connected to one end of the cable 214. The other endof the cable 214 is connected to the power source unit 213. The knob 218is fixed to, for example, the ultrasonic probe 216, and the knob 218 isrotated to the housing 210, so that the ultrasonic probe 216 can berotated around a central axis C (see FIG. 16A). In addition, when anoperator operates the energy input button 221, the energy controlsection 219 senses an operation input of the energy input button 221.Further, the energy control section 219 controls the ultrasonic currentsupply section 220 to supply power to the vibration generating section215. Consequently, an ultrasonic vibration (ultrasonic energy) istransmitted to the ultrasonic probe 216, and the ultrasonic vibrationcan be imparted to a bone tissue (a biological tissue) of a treatmentobject via the ultrasonic probe 216. In consequence, it is possible toperform excision, removal, debridement and the like of the biologicaltissue.

It is to be noted that the energy input buttons 221 may be disposed. Anamplitude of an ultrasonic vibrator can suitably be set by the energycontrol section 219. In consequence, by the operation of the energyinput button 221, a frequency of the ultrasonic vibration to be outputfrom the after-mentioned ultrasonic vibrator is the same, but theamplitude may be different. Therefore, the energy input button 221 cansuitably switch the amplitude of the ultrasonic vibrator to states suchas two large and small states. For example, when the amplitude can beswitched to the two large and small states, the ultrasonic vibration ofthe small amplitude is for use in treating a comparatively soft tissuesuch as a synovial membrane or a bursa. The ultrasonic vibration of thelarge amplitude is for use in treating a comparatively hard tissue suchas a bone (a bone spur 251).

It is to be noted that, for example, the two energy input buttons 221may be disposed in parallel, or a hand switch and a foot switch mayselectively be used. Additionally, when the one switch 221 is switchedto be used, the ultrasonic vibration of the small amplitude may beoutput by one operation, and the ultrasonic vibration of the largeamplitude may be output by two quick pressing operations as in a doubleclick operation of a mouse for a computer.

The vibration generating section 215 includes piezoelectric elements 222and a horn member 223. The piezoelectric elements 222 receives the powersupplied from the power source unit 213 to generate the ultrasonicvibration. The horn member 223 transmits the ultrasonic vibration to theultrasonic probe 216 while enlarging the amplitude of the ultrasonicvibration generated by the piezoelectric elements 222.

As shown in FIG. 16A and FIG. 16B, the ultrasonic probe 216 is made of,for example, a metal material (e.g., a titanium alloy or the like)having a biocompatibility and is shaped in the form of a rod. Theultrasonic probe 216 has cutting blades 224 on a distal surface 216A, anupper surface 216B and both side surfaces 216C. The cutting blades 224are concentrated on a distal side of the ultrasonic probe 216, and abuton the biological tissue when the biological tissue is treated. Theultrasonic probe 216 is extended toward a back surface 216D side so thatan upper surface 216B side is projected.

Next, Bankart repair to be performed under the arthroscope will bedescribed with reference to FIG. 17 to FIG. 23D. The Bankart repair isperformed for the purpose of treating recurrent shoulder jointdislocation. The Bankart repair is carried out while circulating theperfusion liquid through the shoulder joint by a well-known method.

As shown in FIG. 17, the patient is fixed at, for example, a beach chairposition. Needless to say, the patient may be fixed at a lateralrecumbent position. FIG. 18 shows a position of a scapula upper armjoint 225 (the shoulder joint), and FIG. 19 shows an inner structure ofthe scapula upper arm joint 225 (the shoulder joint). FIG. 18 shows aclavicle 226, a scapula 227, an acromion 228, a humerus 231 and thelike, and shows the scapula upper arm joint 225 at a position surroundedby a circle. In FIG. 19, a head 231A of the humerus 231 faces a labrumligament complex 232. Their peripheries are covered with a ligament 230.FIG. 19 shows a state where a labrum 232A of the labrum ligament complex232 is sutured at an anatomically correct position to a glenoid 233, andthe treatment is completed. FIG. 20 shows portals 234 to approach theinside of the shoulder joint. The portals 234 include an anterior portal234A, an anterosuperior portal 234B, a side portal 234C and a posteriorportal 234D. A tubular cannula 235 or the like is inserted into each ofthe portals 234 (see FIG. 25A), so that the inside of the shoulder joint200 can be accessed from the outside.

In the Bankart repair, the arthroscope 204 is inserted into the shoulderjoint 200 via the posterior portal 234D. In addition, the ultrasonicprobe 216 is inserted into one of the anterior portal 234A, the anteriorand superior portal 234B and the side portal 234C to position this probein the shoulder joint 200.

In a state seen with the arthroscope 204, the labrum ligament complex232 of a damaged region is peeled from the glenoid 233 by use of theultrasonic probe 216. In the present embodiment, as shown in FIG. 22, byusing the cutting blades 224 of the side surfaces 216C of the ultrasonicprobe 216 and the side surfaces 216C, the labrum 232A can be peeled fromthe glenoid 233. Additionally, as shown in FIG. 21, a torn region of thelabrum ligament complex 232 is debrided by using the ultrasonicallyvibrated ultrasonic probe 216. The debridement can be performed bymainly using the cutting blades 224 of the upper surface 216B of theultrasonic probe 216.

As shown in FIG. 23B, the labrum ligament complex 232 is peeled from thescapula glenoid 233, and as shown in FIG. 23C, an anchor 236A of anchorsand sutures 236 is first fixed to a hard tissue (a bone or the like) ona glenoid 233 side. Subsequently, as shown in FIG. 23D, the labrum 232Ais fixed to the scapula glenoid 233 by sutures 236B. Consequently, thelabrum ligament complex 232 is disposed at its anatomically correctposition. Additionally, although not shown, an articular capsule presentaround the complex can be sutured and contracted or fixed at itsanatomically correct position by the anchors and sutures 236. As shownin FIG. 23A, the labrum 232A is fixed to regions by the anchors andsutures 236, and hence the labrum 232A is held at the correct positionof the scapula glenoid 233. As described above, the Bankart repair iscompleted.

Next, shoulder rotator cuff repair will be described with reference toFIG. 24 to FIG. 31. The shoulder rotator cuff repair includes repair ofa subscapular muscle tendon, repair of a supraspinatus tendon presentunder the acromion, removal of a subacromial bone spur (arthroscopicsubacromial decompression) and the like, and the repair to be carriedout varies depending on a condition of an affected area of the patient.The shoulder rotator cuff repair is carried out while circulating theperfusion liquid through the shoulder joint by the well-known method.

In the shoulder rotator cuff repair, the arthroscope 204 is insertedinto the shoulder joint via, for example, the posterior portal 234D.Additionally, in the shoulder rotator cuff repair, the ultrasonic probe216 is inserted into one of the anterior portal 234A, the anterior andsuperior portal 234B and the side portal 234C to position this probe inthe shoulder joint.

First, it is assumed that the operator confirms tears in a subscapularmuscle tendon 237 under the arthroscope 204. In this case, as shown inFIG. 24, a tendon remaining in a torn region (a humerus nodule footprintregion 238A) of the subscapular muscle tendon 237 is debrided with theultrasonic probe 216 which ultrasonically vibrates. In a state where thefootprint region 238A is clean, the anchor 236A of the anchors andsutures 236 is fixed to the humerus 231 (see FIG. 25B). Further, asshown in FIG. 25A and FIG. 25B, the subscapular muscle tendon 237 isfixed to the humerus 231 by using the sutures 236B. It is to be notedthat the fixing of the subscapular muscle tendon 237 by the anchors andsutures 236 may be performed together with fixing of a supraspinatustendon 249 after a footprint region 238B of the supraspinatus tendon iscleaned and the bone spur 251 under the acromion 228 is removed asdescribed later.

Prior to the repair of the supraspinatus tendon, the position of thebursa present in the shoulder joint will be described with reference toFIG. 26. On a superior side of the humerus 231 and an inferior side ofthe acromion 228, a subacromial bursa 241 is positioned to cover thehumerus 231, and a subdeltoid bursa 242 is adjacent to this subacromialbursa. Superior sides of these bursas are covered with a deltoid 243. Anarticular capsule 244 is adjacent to the subacromial bursa 241 and thesubdeltoid bursa 242. A subscapular muscle 245 is connected to thehumerus 231, and a coracoid process 246 is projected in the vicinity ofthe acromion 228. A coracoacromial ligament 247 is positioned along bothof the coracoid process 246 and the acromion 228. Additionally, thehumerus 231 is connected to the subscapular muscle tendon 237. Inaddition, the supraspinatus tendon 249 shown in FIG. 30 passes through alower side of the acromion 228 to be fixed to the humerus 231.

Here, it is assumed that the operator confirms such a tear as shown by Aof FIG. 27 in a cuff 248 of a region corresponding to the supraspinatustendon 249 under the arthroscope 204. In this case, the ultrasonic probe216 is first ultrasonically vibrated to remove the subacromial bursa 241present around the cuff 248.

Further, the ultrasonic probe 216 is positioned in the vicinity of thecuff 248. As shown in FIG. 28, the ultrasonic probe 216 isultrasonically vibrated to debride a periphery of the torn cuff 248. Inaddition, a tendon remaining at a position of a root of thesupraspinatus tendon 249 (the humerus nodule footprint region 238B, seeFIG. 30) is similarly debrided and cleaned by ultrasonically vibratingthe ultrasonic probe 216. Additionally, the coracoacromial ligament 247is excised by using the ultrasonically vibrated ultrasonic probe 216,and the cuff 248 of the region corresponding to the supraspinatus tendon249 is sufficiently peeled from the humerus 231. It is to be noted that,even when a bursa such as the subacromial bursa 241 is removed forregeneration, there usually are not any problems.

Next, as shown in FIG. 29, the bone spur 251 present under the acromion228 is removed by using the ultrasonic probe 216 which ultrasonicallyvibrates. In FIG. 29, a broken line shows a position of the bone spur251. At this time, as to the ultrasonic probe 216, the ultrasonic probe216 used in the abovementioned removal of the subacromial bursa 241, thecleaning of the cuff 248 and the like can be used as it is.

Thus, in the present embodiment, the removal of the subacromial bursa241, the excision of the torn region of the cuff 248, the cleaning ofthe footprint region 238B of the cuff 248, the excision of thecoracoacromial ligament 247 and the removal of the bone spur 251 underthe acromion 228 can be performed by using the one ultrasonic probe 216.

As shown in FIG. 30, the anchor 236A of the anchors and sutures 236 isfixed to the footprint region 238B of the humerus 231. Further, as shownin FIG. 31, the cuff 248 is fixed to the footprint region 238B of thehumerus 231 by use of the sutures 236B. As described above, the repairof the supraspinatus tendon 249 present under the acromion 228 iscompleted. Finally, the arthroscope 204, the ultrasonic probe 216, thecannula and the like are removed through the respective portals 234, andthe articular capsule and the skin are sutured, to complete the shoulderrotator cuff repair.

According to the present embodiment, in a surgical treatment of theshoulder joint, the arthroscope 204 and the ultrasonic device areinserted into the shoulder joint, and the bursa is removed and the bonespur 251 present under the acromion 228 is removed in a state seen withthe arthroscope 204 by use of the ultrasonic device which ultrasonicallyvibrates.

According to this method, the removal of the soft tissue of the bursa orthe like and the removal of the hard tissue of the bone spur 251 or thelike can be performed with one ultrasonic device, and hence it is notnecessary to perform the treatment while replacing the devices, so thatthe surgical treatment can efficiently be performed and surgicaltreatment time can be shortened. In consequence, burdens on the patientcan be decreased. Additionally, the probe of the ultrasonic device canbe formed into a suitable shape, and the ultrasonic device can be formedto be smaller than a shaver or an abrader burr. Consequently, in thetreatment in which the ultrasonic device is used, a movable range of theultrasonic device can be increased, and a narrow region in a living bodycan easily be approached. Additionally, in the treatment of theultrasonic device, a more precise and smoother treated surface can beformed than in a treatment in which the shaver or the abrader burr isused. In consequence, a patient's smooth joint movement can be realized.

Additionally, the abrader burr abrades the bone (the bone spur) that isthe hard tissue by periaxial rotation, and hence loads that act on theabrader burr increase in a state where the bone is abraded.Consequently, the abrader burr might noticeably entirely be vibrated bythe loads onto the treating portion. On the other hand, the ultrasonicdevice is not periaxially rotated but the bone can be resected only bymoving (vibrating) the ultrasonic device in an axial direction.Consequently, the loads that act on the ultrasonic device during the useare small. In consequence, the ultrasonic device does not noticeablyvibrate. That is, in the state where the bone is resected by thetreating portion, leaping of the treating portion is not caused byrotary motion as in the abrader burr, and hence damages of a peripheraltissue can be decreased.

In addition, a surgeon uses the ultrasonic device and hence does nothave to use a high frequency device. When the treatment is performed byusing the high frequency device, there is the fear that the surface isinvaded by heat. On the other hand, in the case where the ultrasonicdevice is used, a normal biological tissue is less invaded by heat, andthermal necrosis is prevented from being caused to the biologicaltissue.

According to the present embodiment, the arthroscope 204 and theultrasonic device are inserted into the shoulder joint, and thefootprint region 238B of the torn cuff 248 is debrided in the state seenwith the arthroscope 204 by use of the ultrasonic device. According tothis method, the footprint regions 238A and 238B can be debrided byusing the ultrasonic device used in removing the bursa and the bone spur251 as it is, and hence the surgical treatment can further efficientlybe performed, so that the burdens on the patient can be decreased.

In addition, the probe of the ultrasonic device can be formed into thesuitable shape, and the ultrasonic device can be formed to be smallerthan the shaver or the abrader burr. Consequently, in the treatment inwhich the ultrasonic device is used, the movable range of the ultrasonicdevice can be increased, and the narrow region in the living body caneasily be approached. Additionally, in the treatment of the ultrasonicdevice, the more precise and smoother treated surface can be formed thanin the treatment in which the shaver or the abrader burr is used. Inconsequence, the patient's smooth joint movement can be realized.

Additionally, the abrader burr abrades the bone (the bone spur) that isthe hard tissue by the periaxial rotation, and hence the loads that acton the abrader burr increase in the state where the bone is abraded.Consequently, the abrader burr might noticeably entirely be vibrated bythe loads onto the treating portion. On the other hand, the ultrasonicdevice is not periaxially rotated but the bone can be resected only bymoving (vibrating) the ultrasonic device in the axial direction.Consequently, the loads that act on the ultrasonic device during the useare small. In consequence, the ultrasonic device does not noticeablyvibrate. That is, in the state where the bone is resected by thetreating portion, the leaping of the treating portion is not caused bythe rotary motion as in the abrader burr, and hence damages of theperipheral tissue can be decreased.

In addition, the surgeon uses the ultrasonic device and hence does nothave to use the high frequency device. When the treatment is performedby using the high frequency device, there is the fear that the surfaceis invaded by heat. On the other hand, in the case where the ultrasonicdevice is used, the normal biological tissue is less invaded by heat,and the thermal necrosis is prevented from being caused to thebiological tissue.

Additionally, according to the present embodiment, in the surgicaltreatment of the shoulder joint, the arthroscope 204 and the ultrasonicdevice are inserted into the shoulder joint, and the labrum ligamentcomplex 232 is peeled from the scapula glenoid 233 and a damaged regionof the labrum ligament complex 232 is debrided in the state seen withthe arthroscope 204 by use of the ultrasonic device which ultrasonicallyvibrates.

According to this method, the peeling of the labrum ligament complex 232and the debridement of the damaged region of the labrum ligament complex232 can be performed with one ultrasonic device, and the treatment doesnot have to be performed while replacing the devices, so that thesurgical treatment can efficiently be performed and the surgicaltreatment time can be shortened. In consequence, the burdens on thepatient can be decreased.

In addition, the probe of the ultrasonic device can be formed into thesuitable shape, and the ultrasonic device can be formed to be smallerthan the shaver or the abrader burr. Consequently, in the treatment inwhich the ultrasonic device is used, the movable range of the ultrasonicdevice can be increased, and the narrow region in the living body caneasily be approached. Additionally, in the treatment of the ultrasonicdevice (see FIG. 9A), the more precise and smoother treated surface canbe formed than in the treatment in which the shaver or the abrader burris used (see FIG. 9B). In consequence, the patient's smooth jointmovement can be realized.

Additionally, the abrader burr abrades the bone (the bone spur) that isthe hard tissue by the periaxial rotation, and hence the loads that acton the abrader burr increase in the state where the bone is abraded.Consequently, the abrader burr might noticeably entirely be vibrated bythe loads onto the treating portion. On the other hand, the ultrasonicdevice is not periaxially rotated but the bone can be resected only bymoving (vibrating) the ultrasonic device in the axial direction.Consequently, the loads that act on the ultrasonic device during the useare small. In consequence, the ultrasonic device does not noticeablyvibrate. That is, in the state where the bone is resected by thetreating portion, the leaping of the treating portion is not caused bythe rotary motion as in the abrader burr, and hence the damages of theperipheral tissue can be decreased.

In addition, the surgeon uses the ultrasonic device and hence does nothave to use the high frequency device. When the treatment is performedby using the high frequency device, there is the fear that the surfaceis invaded by heat. On the other hand, in the case where the ultrasonicdevice is used, the normal biological tissue is less invaded by heat,and the thermal necrosis is prevented from being caused to thebiological tissue.

Furthermore, needless to say, it is possible to combine the Bankartrepair with one or all of the treatments described in the shoulderrotator cuff repair, thereby constituting one surgical treatment.

Elbow Joint

When treating the elbow joint 300, as in the case of treating the kneejoint 100 (see FIG. 1), treatment system 10 shown in FIG. 32 is used.

A structure of the elbow joint 300 will briefly be described. FIG. 33 toFIG. 35 are views showing the elbow joint 300. FIG. 33 shows a casewhere the right elbow joint 300 is seen from an anterior side of a humanbody (in a stretching posture on a front side), and FIG. 34 shows a casewhere the right elbow joint 300 is seen from a posterior side of thehuman body (in the stretching posture on a rear side). Additionally,FIG. 35 is a view schematically showing the right elbow joint 300together with an after-mentioned joint capsule 335 and the cartilages312 a, 314 a and 316 a. As shown in FIG. 33 to FIG. 35, the elbow joint300 is a joint formed of the humerus 312, the ulna 314, and a radius316.

As shown in FIG. 33 and FIG. 34, the humerus 312 has a medial epicondyle321, a lateral epicondyle 322, a capitulum 323 of the humerus, atrochlea 324 of the humerus, a coronoid fossa 325, and an olecranonfossa 326 on an elbow joint 300 side. Additionally, the ulna 314 has anolecranon 331 and a coronoid process 332 on the elbow joint 300 side.Further, the radius 316 has a radial head 333 on the elbow joint 300side.

As shown in FIG. 35, the elbow joint 300 is encapsulated in the jointcapsule 335. The joint capsule 335 is formed of an outer fibrous tunica336 and the inner synovial membrane 337. The synovial membrane 337 formspleats and secretes a synovial fluid, and hence the elbow joint 300smoothly moves. The inside of the joint capsule 335 is called the jointcavity 338, and the joint cavity 338 is filled with the synovial fluidto be secreted from the synovial membrane 337. The joint cavity 338 ofthe elbow joint 300 is incompletely divided into two anterior andposterior cavities.

Additionally, in the elbow joint 300, each of the cartilages (the jointcartilages) 312 a, 314 a and 316 a is present between the bones (thehumerus 312, the ulna 314 and the radius 316). The cartilage 312 a isdisposed on an inferior surface of the humerus 312. Further, thecartilage 314 a is disposed on a superior surface of the ulna 314, andthe cartilage 316 a is disposed on a superior surface of the radius 316.The cartilages 312 a, 314 a and 316 a can absorb impact in the elbowjoint 300 and smoothen movement of the elbow joint 300.

FIG. 36 is a view showing running of nerves in the elbow joint 300 andthe vicinity of the elbow joint. As shown in FIG. 36, a lot of nervesrun in the vicinity of the elbow joint 300. For example, a radial nerve341 runs toward inferior along a posterior surface of the humerus 312,reaches anterior surfaces of the humerus capitulum 323 and the radialhead 333, and runs on a lateral side along the radius 316. Additionally,an ulnar nerve 342 passes through a rear side of the medial epicondyle321 of the humerus 312, and runs on a medial side along the ulna 314. Inaddition, a median nerve 343 runs down on a medial side of the humerus312, and reaches anterior sides of the humerus trochlea 324 and thecoronoid process 332 of the ulna 314.

Next, there will be described a method of performing a surgicaltreatment of removing an osteophyte 345 in the humerus 312 or the ulna314 of the elbow joint 300. In particular, there will be described asurgical treatment of removing the bone spur 345 formed in one of thecoronoid fossa 325 of the humerus 312, the olecranon fossa 326 of thehumerus 312, the coronoid process 332 of the ulna 314, and the olecranon331.

For example, when a pitching action is repeatedly performed in baseball,a trouble of a so-called little league elbow occurs in the elbow joint300. As one of symptoms of the little league elbow, the osteophyte 345might be formed in one of the coronoid fossa 325, the olecranon fossa326, the coronoid process 332, and the olecranon 331. The bone spur 345is formed in one of the coronoid fossa 325, the olecranon fossa 326, andthe coronoid process 332, and hence a joint movement is obstructed. Inaddition, when the symptom of the little league elbow or the likeproceeds, osteoarthritis of an elbow might be caused. In this case,there is a possibility that the synovial membrane 337 causesinflammation and is thickened.

In the surgical treatment, a condition of the elbow joint 300 isconfirmed by using an X-ray, MRI or the like. When the osteophyte 345 isconfirmed in one of the coronoid fossa 325, the olecranon fossa 326, theolecranon 331 and the coronoid process 332, a position or the like ofthe osteophyte 345 is confirmed in advance.

Further, an instrument to form the portals 302 and 304 in the elbowjoint 300, and an instrument for use in the surgical treatment ofremoving the osteophyte 345 are prepared. It is to be noted that thetreating portion 68 of the ultrasonic treatment tool 32 is formed into asuitable shape such as the hook type.

Further, a surgeon forms the portal 302 for the patient who bends theelbow joint 300 of the right elbow (may be a left elbow). Whennecessary, the first cannula 18 a is disposed in the portal 302. Adistal end of the arthroscope 22 is disposed in the joint cavity 338 ofthe elbow joint 300 through the first cannula 18 a. Here, the firstcannula 18 a is not necessarily required, when the perfusion device 16is connectable to the arthroscope 22.

Additionally, in the vicinity of the elbow joint 300, a lot of nerves(the radial nerve 341, the ulnar nerve 342, the median nerve 343, etc.)run. Therefore, it is necessary to form the portal 302 without damagingthe nerves. Therefore, as the portal 302, there is employed one of aproximal anterolateral portal, a distal anterolateral portal, a directlateral portal, an anteromedial portal, a proximal medial portal, astraight posterior portal and a posterolateral portal. It is determinedwhich one of the abovementioned portals is to be employed as the portal302, on the basis of the position of the osteophyte 345 to be removed(i.e., a position of a treated object region).

When the distal end of the arthroscope 22 is disposed in the jointcavity 338, the joint cavity 338 of the elbow joint 300 is filled withphysiological saline by use of the perfusion device 16. In this state,the inside of the joint cavity 338 of the elbow joint 300 is suitablyobserved by using the arthroscope 22. Further, one of the coronoid fossa325, the olecranon fossa 326 and the coronoid process 332 is in a viewfield of the arthroscope 22 to confirm the position of the osteophyte345. In addition, an inflamed condition of the synovial membrane 337 onthe inner side of the joint capsule 335 of the elbow joint 300 isconfirmed.

Further, the surgeon forms the portal 304 for the patient who bends theelbow joint 300. When necessary, the second cannula 18 b is disposed inthe portal 304. The treating portion 68 of the ultrasonic treatment tool32 is disposed in the joint cavity 338 of the elbow joint 300 throughthe second cannula 18 b. Also as the portal 304, there is employed oneof the proximal anterolateral portal, the distal anterolateral portal,the direct lateral portal, the anteromedial portal, the proximal medialportal, the straight posterior portal and the posterolateral portalwhich is different from the portal 302. It is also determined which oneof the abovementioned portals is to be employed as the portal 304, onthe basis of the position of the bone spur 345 to be removed (i.e., theposition of the treatment object region).

When the inflamed region is present in the synovial membrane 337 of thejoint capsule 335 confirmed with the arthroscope 22, as shown in FIG.37, the surgeon adjusts the treating portion 68 of the ultrasonictreatment tool 32 to approach the inflamed region (the treated objectregion) while observing the inflamed region with the arthroscope 22.Further, the surgeon operates the switch 36 of the treatment device 14to generate the ultrasonic vibration of the suitable amplitude in theultrasonic vibrator, thereby only moving the treating portion 68 in anaxial direction of the probe 66, whereby the inflamed region of thesynovial membrane 337 or an inflamed synovial membrane is excised withthe treating portion 68 to which the vibration is transmitted. Theexcised inflamed region of the synovial membrane 337 is flown withmomentum in excising the region. In this case, the surgeon suitablymoves the ultrasonic treatment tool 32 and also suitably moves thearthroscope 22 to excise the inflamed region of the synovial membrane337 or the inflamed synovial membrane pleats with the treating portion68 of the ultrasonic treatment tool 32 while always disposing thetreating portion 68 in the view field of the arthroscope 22. The excisedsynovial membrane 337 is discharged to the suction bottle 50 through thefirst cannula 18 a and the liquid discharge tube 48.

A head (a treating portion) of an unshown shaver that has heretoforebeen used in removing the inflamed region of the synovial membrane 337or the like has a structure to intertwine the inflamed regions byperiaxial rotation. Thus, the shaver performs the treatment whileintertwining (winding) the inflamed regions, and hence there is a highpossibility that the nerves running in the vicinity of the elbow joint300 are wound during the treatment. In addition, driving force issecurely transmitted from a motor of the shaver to the head, and henceit is difficult to form a portion between the motor and the head of theshaver into a suitable shape, and additionally, a head portion of theshaver is formed to be larger than the treating portion 68 of theultrasonic treatment tool 32. In consequence, it is very difficult forthe head portion of the shaver to access the small elbow joint 300.Therefore, even by use of the shaver that has heretofore been used, itmight be difficult to remove the synovial membrane 337. Additionally,when the head portion of the shaver becomes larger, it is necessary touse a cannula having a large diameter, and a portal to be formed is alsolarge. Consequently, there is the high possibility that the nervesrunning in the vicinity of the elbow joint 300 are damaged. On the otherhand, when the treatment is performed by using the ultrasonic treatmenttool 32, it is not necessary to rotate the treating portion 68.Therefore, damages due to the winding of the nerves running in thevicinity of the elbow joint 300 can be decreased. Additionally, in thecase where the treatment is performed by using the ultrasonic treatmenttool 32, as compared with the case where the shaver is used, thetreating portion 68 can be formed into the suitable shape, and thetreating portion 68 can be formed to be smaller, so that a moving rangeof the treating portion 68 with respect to the second cannula 18 b canbe increased. Therefore, in the case where the ultrasonic treatment tool32 is used, the elbow joint 300 can more easily be accessed.Consequently, in the case the ultrasonic treatment tool 32 is used, theinflamed region of the synovial membrane 337 can more easily be excisedthan in the case where the shaver is used. Additionally, when thetreating portion 68 is formed to be smaller, the second cannula 18 bhaving a small diameter is usable, and hence the portal 304 to be formedcan be small. In consequence, the possibility that the nerves aredamaged decreases.

Furthermore, as described above, the shaver has the structure tointertwine the inflamed regions of the synovial membrane 337 by theperiaxial rotation. Consequently, a force to tear off the synovialmembrane 337 acts, and hence bleeding is easily caused. On the otherhand, the treating portion 68 of the ultrasonic treatment tool 32 doesnot periaxially rotate, and the inflamed region can be excised only bymoving the treating portion in the axial direction of the probe 66.Further, in the case where the ultrasonic treatment tool 32 is used, theexcised region is flown unlike the case where the shaver is used, andhence the view field of the arthroscope 22, especially the view field inthe treated object region is easily acquired.

Further, the surgeon removes the inflamed region of the synovialmembrane 337, and then while moving the arthroscope 22 to confirm theinside of the joint cavity 338 of the elbow joint 300, the surgeon movesthe ultrasonic treatment tool 32 to bring the treating portion 68 intocontact with the osteophyte 345 (the treated object region) to be formedin one of the coronoid fossa 325, the olecranon fossa 326, the coronoidprocess 332 and the olecranon 331 as shown in FIG. 38A. That is, thesame treating portion 68 of the ultrasonic treatment tool 32 as theportion used to excise the synovial membrane 337 is brought into contactwith the bone spur 345 without removing out the treating portion fromthe joint cavity 338 of the elbow joint 300.

In the state where the treating portion 68 of the ultrasonic treatmenttool 32 is in contact with the osteophyte 345 (the treated objectregion), the switch 36 is operated to generate the ultrasonic vibrationof the suitable amplitude in the ultrasonic vibrator. In consequence,the treating portion 68 to which the ultrasonic vibration is transmittedis only moved in the axial direction of the probe 66, to resect theosteophyte 345 formed in the treated object region. When the osteophyte345 is resected, the osteophyte 345 is removed as shown in FIG. 38B.That is, dissection is performed by the treating portion 68 to which theultrasonic vibration is transmitted.

An unshown abrader burr that has heretofore been used to resect the bonehas a structure to abrade the bone by the periaxial rotation. Therefore,similarly to the abovementioned shaver, a head portion of the abraderburr is formed to be larger (thicker) than the treating portion 68 ofthe ultrasonic treatment tool 32, and the head portion might havedifficulty in accessing a narrow space where the coronoid fossa 325, theolecranon fossa 326, the coronoid process 332 and the olecranon 331 arepositioned. Additionally, when the head portion of the abrader burr islarge, it is necessary to use a cannula having a large diameter, and aportal to be formed is large. Consequently, there is the highpossibility that the nerves running in the vicinity of the elbow joint300 are damaged. On the other hand, the ultrasonic treatment tool 32more easily accesses the narrow space where the coronoid fossa 325, theolecranon fossa 326 and coronoid process 332 are positioned than theabrader burr. Consequently, in the case where the treatment is performedby using the ultrasonic treatment tool 32, the osteophyte 345 formed inone of the coronoid fossa 325, the olecranon fossa 326 and the coronoidprocess 332 can more easily be removed than in the case where theabrader burr is used. Additionally, when the treating portion 68 issmall, the second cannula 18 b having the small diameter is usable, andthe portal 304 to be formed is small. In consequence, the possibilitythat the nerves are damaged decreases.

Additionally, as shown in FIG. 9B, in the case where the abrader burr isused, a cut-off surface is apt to be made fluffy, and hence it is moredifficult to smoothen the surface and it is easier to generate concaveand convex areas in the excised region. On the other hand, as shown inFIG. 9A, in the case where the treating portion 68 of the ultrasonictreatment tool 32 is used, the precisely and smoothly cut-off surface ismore easily formed than in the case where the abrader burr is used.Therefore, in the case where the ultrasonic treatment tool 32 is used,the concave and convex areas of the excised region can be decreased ascompared with the case where the abrader burr is used. In consequence,by use of the ultrasonic treatment tool 32, a removed surface 347 fromwhich the osteophyte 345 is removed and a non-removed surface 348adjacent to the removed surface 347 are smoothly continued.

Additionally, the abrader burr abrades the bone (the osteophyte 345)that is the hard tissue by the periaxial rotation, and hence loads thatact on the abrader burr increase in a state where the bone is abraded.Consequently, the whole treatment tool including the abrader burr mightnoticeably be swung by the loads. The treatment tool to be inserted intothe joint cavity 338 of the elbow joint 300 through the portalnoticeably swings, and hence there is the high possibility that thenerves running in the vicinity of the elbow joint 300 are damaged. Onthe other hand, the treating portion 68 of the ultrasonic treatment tool32 is not periaxially rotated, but the bone can be cut only by moving(vibrating) the treating portion in the axial direction of the probe 66,and hence the loads that act on the treating portion 68 are small in thestate where the bone is resected by the treating portion 68. Inconsequence, there is decreased a possibility that the ultrasonictreatment tool 32 to be inserted into the joint cavity 338 of the elbowjoint 300 through the portal 304 noticeably swings, and the possibilitythat the nerves are damaged decreases. That is, in the state where thebone is resected by the treating portion 68, leaping of the treatingportion 68 is not caused by rotary motion unlike in the case of theabrader burr, and hence damages of peripheral tissues (e.g., the nerves)can be decreased.

As described above, the osteophyte 345 formed in one of the coronoidfossa 325, the olecranon fossa 326, the coronoid process 332 and theolecranon 331 is removed, and hence the elbow joint 300 can smoothly bemoved. Therefore, the treatment in which the ultrasonic treatment tool32 is used contributes to a smooth joint movement in the elbow joint300.

As described above, the osteophyte 345 is removed, the treating portion68 of the ultrasonic treatment tool 32 is removed out from the secondcannula 18 b, and the distal end of the arthroscope 22 is pulled outfrom the first cannula 18 a. Furthermore, the first and second cannulas18 a and 18 b are removed from the elbow joint 300. Further, the portals302 and 304 are sutured.

As described above, the technique of removing the osteophyte 345 formedin one of the coronoid fossa 325, the olecranon fossa 326, the coronoidprocess 332 and the olecranon 331 can be considered as follows.

By use of the treatment system 10, the surgeon can perform a series oftreatment of excising the synovial membrane 337 and removing theosteophyte 345 formed in one of the coronoid fossa 325, the olecranonfossa 326, the coronoid process 332 and the olecranon 331 with thetreating portion 68 of the treatment tool 32 while the one ultrasonictreatment tool 32 is disposed as it is in the second cannula 18 b.Heretofore, the treatment has been performed by replacing differentinstruments for the portal 304, e.g., using the shaver or the like inexcising the synovial membrane 337 that is the soft tissue and using theabrader burr or the like in removing the osteophyte 345 that is the hardtissue, but the treatment can be performed with the one treatment tool32. In consequence, the surgeon does not have to replace the treatmenttool 32 disposed in the joint cavity 338 during the surgical treatment,and hence surgical treatment time can be shortened.

Next, there will be described a method of excising a damaged region ofthe cartilage under the arthroscope 22. Here, the method of removing thedeformed cartilage is only described, but may be performed together withabove mentioned excision of the synovial membrane 134 and/or theremoving the osteophyte 345 formed in one of the coronoid fossa 325, theolecranon fossa 326, the coronoid process 332 and the olecranon 331. Inthis case, the excision of the cartilage is performed together with theexcision of the synovial membrane 134 and/or the cutting off of the bonespur, without removing the treating portion 68 of the same ultrasonictreatment tool 32 from the joint cavity 338 of the elbow joint 300.

In the elbow joint 300, osteochondritis dissecans (OCD) might be causedby the little league elbow. The osteochondritis dissecans are confirmedusing MRI or the like by the surgeon. Degrees of progress of theosteochondritis dissecans are indicated as, for example, grades of ICRS(International Cartilage Repair Society), i.e., Grade 0 (Normal), Grade1 (Stable, continuity: Softened area covered by intact cartilage), Grade2 (Partial discontinuity, stable on probing), Grade 3 (Completediscontinuity, “dead in situ”, not dislocated), Grade 4 (Dislocatedfragment, loose within the bed or empty defect. >10 mm in depth isB-subgroup). In the elbow joint 300, the cartilages 312 a are damagedin, for example, the lateral epicondyle 322 of the humerus 312 due tothe osteochondritis dissecans.

Further, as like the excision of the synovial membrane 134 and theremoving the osteophyte 345, the portal 302 is formed, and a distal endof the arthroscope 22 is disposed in the joint cavity 338 of the elbowjoint 300 of the right elbow (may be a left elbow) through the firstcannula 18 a to be disposed in the portal 302. Additionally, the portal304 is formed, and the treating portion 68 of the ultrasonic treatmenttool 32 is disposed in the joint cavity 338 of the elbow joint 300through the second cannula 18 b to be disposed in the portal 304. Inthis case, the perfusion device 16 is used to fill the joint cavity 338of the elbow joint 300 with physiological saline. One of theabovementioned portals is to be employed as each of the portals 302 and304, and thereby the portals 302 and 304 is formed without damaging thenerves running in the vicinity of the elbow joint 300.

In a state where the distal end of the arthroscope 22 is disposed in thejoint cavity 338, a condition of the cartilage in the joint cavity 338of the elbow joint 300 is observed. For example, when the cartilage 312a adhered to the lateral epicondyle 322 of the humerus 312 is damaged,the surgeon confirms the grade of the osteochondritis dissecans with thearthroscope 22. By use of the arthroscope 22, the surgeon confirmswhether a part of the cartilage 312 a is softened (Grade 1), whetherlaceration such as partial tear is present in a part of the cartilage312 a (Grade 2), whether a part of the cartilage 312 a is discontinuedfrom a bone (the lateral epicondyle 322 of the humerus 312) to which thecartilage 312 a adheres (Grade 3), or whether a bone cartilage piece isliberated and the bone (the lateral condyle 322 of the humerus 312)having been hidden behind the cartilage 312 a is exposed (Grade 4), tojudge the grade. Additionally, in each of Grades 1 to 4,presence/absence of the bone spurs is confirmed in the lateralepicondyle 322 of the humerus 312. Further, as shown in FIG. 39, thetreating portion 68 of the ultrasonic treatment tool 32 is brought intocontact with the treatment object region while observing the treatedobject region always disposed in the view field of the arthroscope 22.In this state, the switch 36 is operated to suitably perform thetreatment to the treatment object region by use of the ultrasonicvibration.

Here, when the surgeon judges that a condition of a part of thecartilage 312 a is Grade 2, the treating portion 68 of the ultrasonictreatment tool 32 is faced to a torn region of the cartilage 312 a.Further, the torn region of the cartilage 312 a is removed bytransmitting the ultrasonic vibration to the treating portion 68 of theultrasonic treatment tool 32. In addition, the bone spur formed in Grade2 is removed by transmitting the ultrasonic vibration to the treatingportion 68 of the ultrasonic treatment tool 32.

When the surgeon judges that the condition of a part of the cartilage312 a is Grade 3, the treating portion 68 of the ultrasonic treatmenttool 32 is opposed to the torn region of the cartilage 312 a and a tornregion of the lateral epicondyle 322 of the humerus 312. Further, thetorn region of the cartilage 312 a and the torn region of the lateralepicondyle 322 of the humerus 312 are removed together with theosteophyte formed in the lateral epicondyle 322 of the humerus 312 andthe like, by transmitting the ultrasonic vibration to the treatingportion 68 of the ultrasonic treatment tool 32. In this case, anamplitude of an ultrasonic vibrator in treating the torn region of thecartilage 312 a adhered to the lateral epicondyle 322 of the humerus 312may be different from an amplitude in treating the torn retion of thelateral epicondyle 322 of the humerus 312.

When the surgeon judges that the condition of a part of the cartilage312 a is Grade 4, the cartilage 312 a might peel from the lateralepicondyle 322 of the humerus 312. In this case, when the bone under thecartilage 312 a undergoes necrosis due to an interruption in circulationof blood or the like, the bone cartilage piece separates to be liberatedas a loose body in the joint capsule 335. In addition, the loose bodymight be separated also from the cartilage 312 a in the joint capsule130. In such a case, the treating portion 68 of the ultrasonic treatmenttool 32 is faced to the torn region of the cartilage 312 a and the tornregion of the lateral epicondyle 322 of the humerus 312. Further, thetorn region of the cartilage 312 a and the torn region of the lateralepicondyle 322 of the humerus 312 are removed together with theosteophyte formed in the lateral epicondyle 322 of the humerus 312, bytransmitting the ultrasonic vibration to the treating portion 68 of theultrasonic treatment tool 32. Also at this time, the cartilage 312 a issmoothened, and the exposed lateral epicondyle 322 of the humerus 312 issmoothened. It is to be noted that the region (loose body) liberatedfrom the cartilage 312 a is sucked or curetted to be removed.

Thus, in accordance with the condition of damaged region of thecartilage 312 a, the ultrasonic vibration is transmitted to the treatingportion 68 of the ultrasonic treatment tool 32, to suitably dissect thecartilage 312 a. The cartilage 312 a is suitably dissected so that theelbow joint 300 can be smoothly moved.

Further, in the treatment of removing the cartilage, the radio frequencydevice (RF device) has been heretofore used in the cutting-off of thecartilage which is a soft tissue and the abrader burr has beenheretofore used in the removing of the bone which is hard tissues. Theabrader burr performs the cutting off by the periaxial rotation asdescribed above, and hence, when the cartilage is cut off with theabrader burr, a cut-off surface of the cartilage tends to be made fluffyas shown in FIG. 9B. Consequently, when the cartilage is abraded withthe abrader burr, it is difficult to smoothen the cut-off surface and itis easier to generate concave and convex areas in the excised region. Inaddition, when the cartilage 112 a is cut off with the abrader burr, asshown in FIG. 40B, a corner 353 is formed between a removed surface 351from which the cartilage is removed and each of non-removed surfaces 352adjacent to the removed surface 351.

In addition, when a radio frequency device is used to remove thecartilage, heat is generated by a radio frequency current flowingthrough the cartilage. Consequently, as shown in FIG. 9C, there is thefear that the cartilage is invaded by heat.

On the other hand, in the case where the cartilage is cut off with thetreating portion 68 of the ultrasonic treatment tool 32, as shown inFIG. 9A, a more precise and smoother cut-off surface can be formed thanin the case where the abrader burr is used. In consequence, the excisedregion of the cartilage by the treating portion 68 of the ultrasonictreatment tool 32 has less concave and convex areas and is smoothened.In addition, when the cartilage is cut off with the ultrasonic treatmenttool 32, as shown in FIG. 40A, a region between the removed surface 351from which the cartilage is removed and each of the non-removed surfaces352 adjacent to the removed surface 351 is continuous as a smoothsurface in which any corners are not formed.

Further, the cartilage is cut off with the ultrasonic treatment tool 32by use of the ultrasonic vibration, and hence the radio frequencycurrent does not flow through the cartilage. Consequently, in thecartilage (312 a) and the bone (lateral epicondyle 322 of the humerus312) adjacent to the cartilage, a heat invasion is reduced, and thermalnecrosis is prevented from being caused to the cartilages.

In addition, in the treatment of removing the cartilage, the cartilage(312 a) and the bone (lateral epicondyle 322 of the humerus 312) areremoved by use of the same ultrasonic treatment tool 32, and thetreatment tool 32 does not have to be replaced with respect to theportal 304. Hence, the surgical treatment time can be shortened.

Additional advantages and modifications will readily occur to thoseskilled in the art. Therefore, the invention in its broader aspects isnot limited to the specific details and representative embodiments shownand described herein. Accordingly, various modifications may be madewithout departing from the spirit or scope of the general inventiveconcept as defined by the appended claims and their equivalents.

What is claimed is:
 1. A joint surgical treatment which is to beperformed under an arthroscope, the surgical treatment comprising:inserting the arthroscope and a treating portion of an ultrasonic deviceinto a joint; excising a treatment object region of a synovial membrane,by transmitting an ultrasonic vibration to the treating portion in astate where the treating portion is in contact with the treatment objectregion of the synovial membrane while observing the treating portion ofthe ultrasonic device and the treatment object region of the synovialmembrane with the arthroscope; approaching and facing the treatingportion of the ultrasonic device to a treatment object region of acartilage, the treating portion of the ultrasonic device being used inexcising the treatment object region of the synovial membrane; andremoving the treatment object region of the cartilage, by bringing thetreating portion of the ultrasonic device into contact with thetreatment object region of the cartilage, and by transmitting theultrasonic vibration to the treating portion in a state where thetreating portion is in contact with the treatment object region of thecartilage while observing the treating portion and the treatment objectregion of the cartilage with the arthroscope.
 2. The surgical treatmentaccording to claim 1, wherein the removing of the treatment objectregion of the cartilage comprises forming a dented region having asubstantially circular vertical cross section when removing thetreatment object region of the cartilage, and smoothly continuing aremoved surface from which the treatment object region of the cartilageis removed and a non-removed surface adjacent to the removed surface. 3.The surgical treatment according to claim 1, wherein the ultrasonicvibrations of different amplitudes are transmitted to the treatingportion of the ultrasonic device for use in excising the treatmentobject region of the synovial membrane and removing the treatment objectregion of the cartilage.
 4. The surgical treatment according to claim 3,wherein the amplitude of the ultrasonic vibration in excising thetreatment object region of the synovial membrane is smaller than inremoving the treatment object region of the cartilage.
 5. The surgicaltreatment according to claim 1, comprising: approaching and facing thetreating portion of the ultrasonic device to a bone spur, the treatingportion of the ultrasonic device being used in removing the treatmentobject region of the synovial membrane and removing the treatment objectregion of the cartilage; and removing the bone spur, by bringing thetreating portion of the ultrasonic device into contact with the bonespur, and by transmitting the ultrasonic vibration to the treatingportion in a state where the treating portion is in contact with thebone spur while observing the treating portion and the bone spur withthe arthroscope.
 6. The surgical treatment according to claim 5, whereinthe removing of the bone spur comprises forming a dented region having asubstantially circular vertical cross section when removing bone spur,and smoothly continuing a removed surface from which the bone spur isremoved and a non-removed surface adjacent to the removed surface. 7.The surgical treatment according to claim 5, wherein the ultrasonicvibrations of different amplitudes are transmitted to the treatingportion of the ultrasonic device for use in excising the treatmentobject region of the synovial membrane, removing the treatment objectregion of the cartilage and removing the bone spur.
 8. The surgicaltreatment according to claim 7, wherein the amplitude of the ultrasonicvibration in excising the treatment object region of the synovialmembrane is smaller than in removing the treatment object region of thecartilage, and the amplitude of the ultrasonic vibration in removing thebone spur is larger than in removing the treatment object region of thecartilage.